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SAJOUS'S 

Analytic  Cyclopedia 

OF 

Practical  Medicine 

BY 

CHARLES  E.  de  M.  SAJOUS,  M.D.,  LL.D.,  Sc.D. 

•  ASSISTED    BY 

LOUIS  T.  de  M.  SAJOUS,  B.S.,  M.D. 

WITH    THE   ACTIVE   CO-OPERATION    OF   OVER 

ONE    HUNDRED    ASSOCIATE    EDITORS 


SEVENTH 

ENTIRELY  REVISED  AND  GREATLY  ENLARGED 

EDITION 


miixstratet)  witb  3f ulUpage  1balf*tone  an^  Color  plates 
ant)  Hppropriate  Cuts  in  tbe  Ueit 


VOLUME   One 


PHILADELPHIA 

F.  A.  DAVIS  COMPANY,  PUBLISHERS 

1919 


COPYRIGHT,   1918 

BY 

F.  A.    DAVIS   COMPANY 

Copyright,  Great  Britain.     All  Rights  Reserved 


PRESS    OF 

F.     A.     DAVIS    COMPANY 

PHILADELPHIA.  U.S.A. 


PREFACE 

TO   THE  SEVENTH  EDITION 


It  is  perhaps  unnecessary  to  inform  the  reader,  so  apparent  is  the 
fact,  that  the  present  edition  amounts  practically  to  a  new  work.  So 
extensive  have  been  the  additions  over  and  above  all  the  preceding  edi- 
tions that,  exclusive  of  the  index,  over  2000  pages  were  required  to 
accommodate  them.  These  additions  have  consisted  mainly  of  a  large 
number  of  entirely  new  articles  on  practical  medicine,  surgery,  therapeu- 
tics, gynecology,  obstetrics,  dermatology,  ophthalmology,  laboratory 
diagnosis,  etc.,  and  of  completely  rewritten  and  enlarged  articles.  As  the 
reader  can  readily  see  also,  the  work  appears  in  different  type — additional 
evidence  to  the  effect  that  all  opportunity  to  introduce  any  amount  of  new 
matter  was  afforded  to  the  editor's  distinguished  collaborators. 

The  purpose  of  the  work  remains  what  it  was  designed  to  be  from 
the  staVt,  i.e.,  to  assist  the  practitioner  in  his  daily  labors  by  enabling  him 
to  obtain  all  the  practical  information  available  of  value  in  the  vast 
domain  of  Medicine  in  all  its  applied  branches.  What  this  means  in  the 
present  connection  can  be  readily  surmised  from  the  fact  that  the  clinical 
index  alone,  which  includes  only  the  remedial  measures  mentioned  in  the 
body  of  the  work,  exceeds  200  pages.  This  clinical  index,  which  has  for 
its  purpose  to  afford  a  ready  reference  in  emergency  work,  and  is  intended 
to  be  kept  on  the  physician's  desk,  includes  over  18,000  hints  in  the  field 
of  applied  therapeutics,  including  all  the  modern  methods  of  chemo- 
therapy, vaccine  therapy,  organotherapy,  serum  therapy,  psychotherapy, 
etc. — an  aggregate  unequaled  so  far  by  any  medical  work  of  its  size. 

The  presentation  of  such  an  array  of  remedial  resources,  besides 
considerable  material  covering  the  other  classic  subdivisions  of  disease: 
symptomatology,  diagnosis,  pathology,  etiology,  etc.,  was  rendered  pos- 
sible only  by  a  widespread  search  into  the  literature  of  each  of  the  sub- 
jects treated".  This  labor,  undertaken  by  the  central  staff,  is  represented 
by  the  small-type  matter  inserted  in  each  article.  This  small-type  text 
serves  also  to  present  confirmatory  evidence  of  the  views  incorporated  in 
the  large-type  articles,  and  to  furnish  the  reader  what  newer  views  or 
suggestions  of  practical  interest  and  of  special  value  the  literature  of  the 
last  ten  vears  contains. 

(iii) 


iv  PREFACE. 

Besides  the  regular  drugs  of  the  Pharmacopeia  in  actual  use,  there 
have  been  added  a  number  of  proprietary  drugs  which  have  received  the 
sanction  of  the  profession  at  large  or  of  the  Council  of  Pharmacy.  So 
many  of  these  agents  are  commonly  employed  nowadays  that  to  omit 
them  altogether  is  to  deprive  the  reader  of  considerable  therapeutic 
assistance. 

Again,  to  further  facilitate  the  work  of  the  practitioner,  there  have 
been  added  to  the  subject-matter  a  series  of  articles  in  small  type,  in 
which  are  given  in  succinct  form  the  least  complicated  of  the  clinical 
microscopic  and  chemical  diagnostic  methods,  without  which  the  modern 
physician  cannot  fully  do  justice  to  his  professional  work.  Such  all- 
important  topics  as  albuminuria,  acetonuria,  etc.,  are  ranked  with  the 
general  articles,  however,  and  treated  in  full. 

Expressions  of  gratitude  are  due  to  the  editor's  associates  and  collab- 
orators, all  masters  in  their  chosen  field.  Had  it  not  been  for  their 
generous  co-operation  in  the  preparation  of  the  general  articles,  so  com- 
prehensive a  work  could  not  have  been  brought  to  a  successful  issue. 

C.  E.  DE  M.  Sajous. 


CONTRIBUTORS  TO  VOLUME  I. 


ROBERT  T.  MORRIS,  M.D., 

Professor  of  Surger}^  Post-Graduate  Medical  School, 
New  York  City. 

ERNEST  LAPLACE,  M.D.,  LL.D., 

Professor  of  Surgery  and  Clinical  Surgery,  Medico-Chirurgical  College, 

Philadelphia,  Pa. 

A.  H.  WRIGHT,  B.A.,  M.D., 

Professor  of  Obstetrics,  University  of  Toronto, 

Toronto,  Ont. 

JOHN  B.  DEAVER,  M.D., 

Professor  of  Clinical  Surgery,  University  of  Pennsylvania, 

Philadelphia,  Pa. 

H.  W.  STELWAGON,  M.D., 

Professor  of  Dermatology,  Jefferson  Medical   College, 

Philadelphia,  Pa. 

P.  E.  LAUNOIS,  M.D.,  Sc.D., 

Professor  Agrege  of  Medicine  in  the  Faculty  of  Paris, 

AND 

M.  H.  CESBRON,  M.D., 
Paris,  France. 

RUFUS  B.  SCARLETT,  M.D., 

Assistant  Physician  in  the  Department  of  Laryngology,  University  of  Pennsylvania, 

Philadelphia,  Pa. 

J.  P.  LANGLOIS,  M.D., 

Professor  Agrege  of  Medicine  in  the  Faculty  of  Paris, 

Paris,  France. 

W.  WAYNE  BABCOCK,  A.M.,  M.D., 

Professor  of  Surgery  and  Clinical  Surgery,  Temple  University,  ■ 
Philadelphia,  Pa. 

FRANCIS  X.  DERCUM,  M.D., 

Professor  of  Nervous  and  Mental  Diseases,  Jefferson  Medical  College, 

Philadelphia,  Pa. 

(v) 


VI 


COXTRIBUTORS    TO    VOLUME    1. 

FREDERICK  P.  HEXRY,  A.M.,  M.D., 

Professor  of  Medicine,  Woman's  Medical  College, 

Philadelphia,  Pa. 

JAY  F.  SCHA^IBERG,  A.B.,  M.D., 

Professor  of  Dermatology  and  Syphilolog}%  Temple  University, 
Philadelphia,  Pa. 

HOAVARD  S.  HANSELL,  M.D., 

Professor  of  Ophthalmology',  Jefferson  Medical  College, 

Philadelphia,  Pa. 

HERMAX  F.  VICKERY,  M.D., 

Assistant  Professor  of  Medicine,  Harvard  Medical  School, 
Boston,  Mass. 

F.  LEVISOX,  ^I.D.,  AXD  A.  ERLAXDSEX,  M.D., 
Copenhagen',  Denmark. 

C  SUMNER  AVITHERSTIXE,  ^I.S.,  ^I.D., 

Lecturer  on  Dietetics,  Medical  Department,  Temple  University, 

Philadelphia,  Pa. 

E.  E.  AIOXTGOMERY,  M.D.,  LL.D., 

Professor  of  Gynecology',  Jefferson  Medical  College, 
Philadelphia,  Pa. 

J.  C.  Da  COSTA,  Jr.,  ^I.D., 

Assistant  Professor  of  Clinical  Medicine,  Jefferson  Medical   College, 
Philadelphia,  Pa. 

CHARLES  H.  KXIGHT,  M.D., 
Surgeon  to  the  Throat  Department,  Manhattan  Eye  and  Ear  Hospital,  etc., 

New  York  City. 

-   T.  D.  CROTHERS,  M.D., 
Professor  of  Mental  Diseases,  College  of  Physicians  and  Surgeons,  Boston,  Mass., 

Hartford,  Conn. 

C.  E.  DE  M.  SAJOUS,  M.D.,  LL.D.,  Sc.D., 

Professor  of  Pharmacology  and  Therapeutics,  Temple  University, 

Philadelphia,  Pa. 

L.  T.  DE  M.  SAJOUS,  B.S.,  M.D., 

Associate  Professor  of  Pharmacology,  Temple  University, 

Philadelphia,  Pa. 


CONTENTS  OF  FIRST  VOLUME. 


PAGE 

Abdomen,  Surgery  of  1 

The  Fourth  Era  in  Surgery  1 

Anteoperative  Management  3 

Instruments  and  Apparatus  6 

Scissors 6 

Needles 6 

Retaining  Apparatus 6 

Drainage    Tubes    7 

Suture  Materials  7 

Postoperative   Treatment    8 

Thirst    9 

Diet   9 

Opiates    10 

Insomnia  ....'. 10 

Postoperative  Complications  11 

Shock    : 11 

Meteorism  of  Extreme  Degree 12 

x\cute  Dilatation  of  the  Stomach  . .  13 
Meteorism    due    to    Mechanical    Ob- 
struction of  the  Bowel  ....  14 

Colon    Bacillus    Nephritis    14 

Meteorism     due     to     Extension     of 

Peritonitis    15 

Poisoning  by  Bichloride  of  Mercury 

and  by  Iodoform 16 

Uncontrollable  Vomiting   17 

Properitoneal   Hernia    17 

Hernia  into  a  Rent  in  the  Omentum.  17 

Perforation  of  the   Bowel    17 

Postoperative    Phlebitis    17 

Pylephlebitis    18 

Secondary   Abscess    18 

Mesenteric   Thrombosis    18 

Bladder   Complications    18 

Postoperative    Psychoses    18 

Peritoneal   Adhesions    19 

Postoperative    Pneumonia    19 

Pleurisy    20 

Fistulie 20 

Objects  Left  Behind   21 

Secondary    Hemorrhage 22 

Toilet  of  the  Peritoneum  24 

Drainage  of  the  Peritoneal  Cavity  ...  25 

Hemostasis    27 

External  Incisions    27 

Exploratory  Operations    33 

Peritoneal   Adhesions 33 

Intestinal    Sutures    36 

McGraw    Ligature    37 

Murphy's    Button    37 

Two-stage    Operations    37 


PAGB 

Abdomen,  Surgery  of  {continued). 

Surgical  Diseases  of  the  Stomach 38 

Gastric  and  Duodenal  Ulcers   38 

Carcinoma   39 

Congenital   Stenosis  of  Pylorus    ...  40 

Hour-glass  Stomach    40 

Non-obstructive    or    Atonic    Dilata- 
tion      40 

Gastroptosis    41 

Foreign    Bodies     41 

Stricture  of  the  Esophagus    41 

Typical    Operations    upon    the    Stom- 
ach     41 

Gastroplication  41 

Gastric    Omentoplication    42 

Gastrotomy    43 

Pyloroplasty  (Heinecke-Mikulicz 

Operation)     43 

Pyloroplasty  by  Finney's    (Gould's) 
Method    and    Gastroduode- 

nostomy    44 

Gastrostomy    45 

Gastrorrhaph}^    47 

Gastroplasty    48 

Gastrogastrostomy    48 

Partial    Gastrectomy    48 

Complete   Gastrectomy    51 

Surgical  Diseases  of  the  Peritoneum  .  52 

Septic   Peritonitis    57 

Tuberculous   Peritonitis    54 

Ascites    55 

Surgery     of     the      Mesentery     and 

Omentum    57 

Surgical  Diseases  of  the  Intestines  .  57 

Ileus    57 

Volvulus     58 

Intussusception 58 

Typhlitis 59 

Meckel's   Diverticulum    59 

Wounds,   Perforation   from  Within, 

etc 60 

Tvpical  Operations  of  the  Intestine  ..  60 

Enterorrhaphy    60 

Enterectomy    61 

Enteroanastomoses   63 

Gastroenterostomy    64 

Anterior  Gastroenterostomy   66 

Posterior   Gastroenterostomy    67 

End-to-end   Anastomosis    after    En- 
terectomy    70 

Lateral  Anastomosis    71 

(vii) 


CONTEXTS. 


PAGE 

Abdomen,  Surgery  of.  Typical  Opera- 
tions of  the  Intestine  (continued). 

Enteroexclusion  72 

Enterostomy,      Jejunostomy,      Ileos- 
tomy      73 

Surgery  of  the  Appendix   74 

Colostomy    76 

Lilienthal's    Colostomy    80 

Appendicostomy  and  Cecostomy   ...  81 

Appendicostomy    82 

Cecostomy   83 

Colectomy    88 

Cecectomy    88 

Sigmoidectomy    89 

Surgical  Afifections  of  the  Pancreas   .  90 

Acute   Pancreatitis    90 

Cancer    91 

Cysts    91 

Calculi 92 

Pancreatectomy    92 

Pancreaticotomy    93 

Pancreaticostomy  and  Pancreaticoen- 

terostomy  93 

Surgical  Affections  of  the  Spleen  ....  93 

Abscess  93 

Cysts 93 

Splenomegaly    94 

Floating  Spleen   94 

Neoplasms   94 

Typical  Operations  of  the  Spleen  ....  94 

Splenectomy    94 

Surgical    Diseases    of    the    Liver    and 

Biliary  Passages 96 

Abscess  of  the  Liver  96 

Subphrenic  Abscess   96 

Cysts  of  the  Liver 97 

Neoplasms  97 

Cirrhosis    97 

.  Hepatoptosis  97 

Cholelithiasis 97 

Cholecystitis    97 

Obliteration    of    Bile-passages    from 

Without    97 

Typical  Operations  on  Biliary  Passages 

and  Liver 97 

Simple  Cystotomy 98 

Cystostomy    98 

Cystectomy    98 

Choledochotomy 100 

Cholecystenterostomy     101 

Excision  of  Liver ;  Hepatectomy  . .  .  101 

Abdominal  Injuries 102 

Contusion  of  the  Abdomen  102 

Symptoms    102 

Diagnosis  107 

Lesions  of  the  Intestinal  Tract  . .  107 

Lesions  of  the  Stomach 110 

Lesions  of  the  Liver   Ill 


PAGE 

Abdominal  Injuries,  Contusions  of  the 
Abdomen,  Diagnosis   {continued). 
Lesions  of  the  Gall-bladder  or  Bil- 
iary Ducts  114 

Lesions  of  the  Spleen  114 

Lesions  of  the  Kidneys 116 

Prognosis 118 

Treatment    120 

Shock    120 

Reaction   122 

Intestines    123 

Stomach   124 

Liver   125 

Spleen   125 

Kidney    126 

Bladder    128 

Wounds  of  the  Abdomen       130 

Non-penetrating  Wounds  130 

Treatment    130 

Penetrating  Wounds   130 

Symptoms    131 

Diagnosis  132 

Intestines    132 

Stomach   133 

Liver   134 

Spleen  135 

Kidneys    135 

Bladder 136 

Prognosis 137 

Intestines   137 

Stomach   138 

Spleen  138 

Kidneys    139 

Bladder 139 

Treatment    139 

Hemorrhage    144 

Perforation   146 

After-treatment   148 

Wounds  Due  to  Military  Firearms  . .  149 

Abortion    152 

Definition  152 

Symptoms    154 

Abortion  During  the  First  Month  . .  156 

Abortion  During  the  Second  Month.  156 
Abortion  from  the  Beginning  of  the 
Third    to    the    End    of    the 

Fourth  Month 157 

Abortion  During  the  Fifth  and  Sixth 

Months   157 

Dangers    158 

Etiology  and  Pathogenesis    159 

Maternal  Causes   159 

Paternal  and  Fetal  Causes 162 

Prognosis 163 

Treatment    164 

Treatment  of  Threatened  Abortion  .  164 

Treatment  of  Inevitable  Abortion  . .  165 

Expectant  Plan   165 


CONTENTS. 


PAGE 

Abortion,  Treatment   (continued). 

Removal  of  the  Uterine  Contents   . .    165 

The  Tampon    167 

Treatment  of  Incomplete  Abortion  .   172 
Curettage  and  Emptying  the  Ute- 
rus at  a  Single   Sitting   ...   173 
Treatment  of  Criminal  Abortion  . . .   174 
Treatment  of  Patient  with  Aborting 

Habit 175 

Aberrant  Forms 176 

Missed  Abortion    176 

Mole    177 

Hydatiform  Mole   177 

Chorioepithelioma   178 

Induced  Abortion   178 

Indications 179 

Method  of  Inducing  Abortion   182 

Abortion,  Tubal  184 

Definition  184 

Symptoms    184 

Complications  187 

Etiology  and  Pathogenesis  189 

Treatment 192 

Abscess  197 

Definition  197 

Varieties 197 

Acute,  or  Warm  198 

Symptoms    198 

Etiology    199 

Pathology 199 

Differential  Diagnosis   200 

Prognosis 201 

Treatment    201 

Internal  Remedies 201 

External  Remedies  202 

Wright's  Bacterial  Vaccines   . . .  202 
Bier's  Hyperemic  Treatment   . .  203 

Antiferment  Treatment 205 

Surgical  Measures    206 

Cold,  or  Tuberculous   209 

Symptoms    209 

Pathology 209 

Differential  Diagnosis   210 

Prognosis 210 

Surgical  Treatment    210 

Aspiration  and  Injections    212 

A.  C.  E.  Mixture.     See  Chloroform. 

Acetanilide    213 

Properties    213 

Dose    214 

Modes  of  Administration  214 

Incompatibles    216 

Contraindications 216 

Physiological  Action 216 

As  Antipyretic   216 

As  Analgesic 217 

On  the  Blood  217 

On  the  Circulation  218 


PAGE 

Acetanilide  (continued). 

Untoward  Effects  and  Acute  Poison- 
ing     218 

Poisoning  by  Absorption 221 

Treatment  of  Acute  Acetanilide  Poi- 
soning     222 

Chronic   Poisoning   222 

Treatment    of    Chronic    Acetanilide 

Poisoning 224 

Applied  Therapeutics  of  Acetanilide   .  225 

Local  Uses 227 

Acetic  Acid  228 

Properties    228 

Uses  and  Dose  228 

Physiological  Action    228 

Acetic  Acid  Poisoning  228 

Treatment   of   Acetic   Acid   Poison- 
ing      229 

Therapeutics   230 

Acetone   Bromoform.     See  Bromine. 
Acetone  Chloroform.     See  Chloretone. 

Acetonuria 231 

Physiological  and  Pathological  Excre- 
tion of  Acetone 231 

Origin  and  Pathological  Significance 
of  Acetone,  Diacetic  Acid, 
and  Betaoxybutyric  Acid  . .  233 

Preliminary  Tests  for  Acetone   237 

Legal's  Test    237 

Le  Nobel's  Test  238 

Fehr's  Test 239 

Chautard's  Test 239 

Definite  Tests  for  Acetone 239 

Lieben's  Iodoform  Test 239 

Gunning's  Test    240 

Reynold's  Test  240 

Penzoldt's  Indigo  Test 240 

Malerba's  Test  240 

Miscellaneous  Tests  241 

Acetozone    242 

Modes  of  Administration 242 

Therapeutics   243 

Acetparamidosalol.     See  Salophen. 

Acetphenetidin   243 

Properties    243 

Dose 243 

Modes  of  Administration  243 

Incompatibilities    244 

Contraindications    244 

Physiological  Action    244 

As  Antipyretic  244 

As  Analgesic 244 

On  the  Circulation  245 

On  the  Blood  246 

Elimination    246 

Untoward  Effects  and  Poisoning  246 

Treatment  of  Acute  Poisoning 249 

Chronic  Poisoning   249 


CONTENTS. 


PAGE 

Acetphenetidin,      Chronic      Poisoning 
(contintied). 

Treatment  of  Chronic  Poisoning  . . .  250 

Therapeutics   250 

As  Antipyretic   250 

As  an  Analgesic 251 

Local  Uses 252 

Acetylene   252 

Acetylene   Poisoning 252 

Treatment  of  Acetylene  Poisoning  .  253 

Acidity   of   the    Gastric   Contents,   Tests 

for    253 

Test-meals  254 

Withdrawal  of  Gastric  Contents 254 

Contraindications   to   the    Use    of   the 

Stomach  Tube 255 

Determination  of  Free  Acids    255 

To  Ascertain  the  Total  Acidity 255 

Lactic  Acid  256 

Butyric  Acid 256 

Acetic  Acid  256 

Acidosis.     See  Autointoxication. 

Acne    256 

Definition  256 

Symptoms    256 

Varieties    257 

Etiology    •. 258 

Pathology    259 

Diagnosis   260 

Treatment    260 

General  Treatment  260 

Local  Treatment   261 

Acne  Bacterin.     See  Bacterial  Vaccines. 

Acne  Rosacea  268 

Definition    268 

Symptoms    268 

Etiology     269 

Pathology    269 

Diagnosis   270 

Prognosis  270 

Treatment    270 

Acne  Vaccine.    See  Bacterial  Vaccines. 

Acoin 274 

Aconite  274 

Preparations  and  Dose   274 

Modes  of  Administration  274 

Local  Use   275 

Incompatibilities     275 

Contraindications     275 

Physiological  Action    275 

Modes  of  Elimination  277 

Aconite   Poisoning    277 

Treatment  of  Aconite  Poisoning  . . ,  279 

Therapeutics    282 

Acrocyanosis.     See  Vascular  System,  Dis- 
orders of,  under  Acroparesthesia. 

Acromeg'aly :    Pierre  Marie's  Disease   . .  285 

Definition  285 


PAGE 

Acromegaly   (continued). 

Symptomatology    287 

The  Hypophyseal  Syndrome  292 

Relationship  Existing  Between  Acro- 
megaly and  Gigantism    ....  304 

Course  and  Duration  310 

Prognosis 311 

Diagnosis   311 

Pathology .   313 

The  Hypophysis 315 

Pathogenesis  321 

Treatment    325 

Actinomycosis 333 

Definition  333 

Symptoms    333 

Cutaneous  Surface   _  333 

Alimentary  Canal   334 

Intestinal  Canal  335 

Genitourinary  Tract 335 

Respiratory  Tract  336 

Brain  337 

Diagnosis  338 

Etiology   339 

Pathology    340 

Inoculation    342 

Cutaneous  Surface  342 

Bronchial  Tubes  and  Lungs   343 

Alimentary  Canal   343 

Prognosis     344 

Treatment    344 

General  344 

Surgical 346 

Electrotechnical   346 

Actinotherapy.     See  Light  Therapy. 
Active  Hyperemia.  See  Hyperemia,  Bier's. 

Actol   347 

Therapeutics   347 

Acupuncture    347 

Technique    ; 347 

Acute  Rhinitis,  or  Acute  Coryza   347 

Definition  347 

Symptomatology    347 

Diagnosis  349 

Etiolog}' 349 

Pathology    352 

Prognosis 352 

Treatment    352 

Addison's  Disease  356 

Symptoms    356 

Pathogenesis  362 

Diagnosis  368 

Treatment   370 

Adenitis    374 

Definition 374 

Varieties 374 

Acute   374 

Symptoms    374 

Diagnosis  376 


CONTEXTS. 


X) 


PAGE 

Adenitis,  Acute   {continued) . 

Etiolog>-    2i76 

Pathology Z77 

Prognosis  378 

Treatment    378 

Chronic    379 

Symptoms    379 

General  Tuberculous  Adenitis  . .  380 
Local  Tuberculous  Adenitis   . . .   380 

Diagnosis   381 

Etiology-    382 

Pathology    383 

Prognosis  384 

Treatment    384 

Adenoid  A'egetations   389 

Definition  389 

Symptoms  and  Diagnosis  389 

Etiolog}-   395 

Pathology 397 

Prognosis 397 

Treatment    403 

Preparation  of  the  Patient   401 

Position  of  the  Patient  402 

Anesthesia   402 

Instruments  and  ^^lethods 405 

Accidents  and  Complications 408 

After-treatment   411 

Adiposis.     See  Obesity. 

Adiposis  Dolorosa ;  Dercum's  Disease  .  .  412 

Definition  412 

Symptoms  and  Course 413 

Xodular  Form 413 

Localized  Diffuse  Form   416 

Generalized  Diffuse  Form 417 

Etiology'    421 

Patholog}'    423 

Diagnosis  428 

Prognosis  429 

Treatment    429 

Adipositas      Cerebralis.        See      Obesity, 

Frohlich's  Disease. 
Adnephrin.     See  Animal  Extracts. 

Adonis  Vernalis 431 

Dose    431 

Physiological  Action 431 

Incompatibilities 432 

Contraindications    432 

Therapeutics   432 

Adrenalin.     See  Animal  Extracts :    Ad- 
renals. 

Adrenals,  Diseases  of  434 

The  Adrenal  Secretion  in  Pulmonary 

and  Tissue  Oxidation   434 

The  Adrenal  Secretion  in  Immunity'  . .  435 

Classification  436 

Terminal  Hypoadrenia  436 

Definition  436 


PAGE 

Adrenals,    Diseases    of.    Classification 
{continued). 

Pathogenesis     and     Symptomatol- 

og}' 436 

Patholog}'    440 

Treatment    441 

Acute     Hyperadrenia     and     Adrenal 

Hemorrhage    444 

Definition  444 

SymptomatologN'     and     Pathogen- 
esis    444 

Etiologj'    447 

Pathology-    449 

Treatment    452 

Hemorrhagic     Pseudocysts     of     the 

Adrenals 453 

Symptoms    453 

Diagnosis  454 

Etiolog}'   455 

Pathology 455 

Prognosis 455 

Treatment    456 

Functional  Hypoadrenia   456 

Definition   456 

Symptomatology     and     Pathogen- 
esis    456 

Infancy  456 

Childhood    457 

Adult  Age  458 

Old  Age 459 

Prophylaxis  and  Treatment  461 

In  the  Infant 461 

In  the  Child  463 

In  the  Adult  464 

In  Old  Age  465 

Progressive  Hypoadrenia  466 

Cancer  of  the  Adrenals  466 

Varieties 466 

Symptoms    467 

Diagnosis   469 

Treatment    470 

H3^pernephroma    471 

S3-mptomatolog}-    472 

]\Ialignant    Hj-pernephroma    of    the 

Adrenals 472 

H3-pernephroma  of  the  Kidnej^  475 

Symptomatology    475 

Diagnosis  477 

Patholog}- 478 

Prognosis 479 

Treatment    480 

Adrin.    See  Animal  Extracts :    Adrenals. 
Agalactia.     See  Mammary  Gland. 

Agar-agar    481 

Agaricin 481 

Dose    481 

Physiological  Action       481 

Therapeutics   482 


XII 


CONTEXTS. 


PAGE 

Agglutination  Test    482 

Agoraphobia.     See  Index-Supplement. 

Agurin 483 

Modes  of  Administration  483 

Therapeutics   483 

Ainhum    483 

Definition  483 

Symptoms    484 

Etiology    484 

Pathology    484 

Treatment    485 

'Airol    ' 485 

Modes  of  Administration  485 

Physiological  Action    485 

Therapeutics   485 

Albargin  486 

Therapeutics   486 

Albuminuria    486 

Definition 486 

Physiological  Albuminuria 487 

Physiological  Cj'clical,  Orthostatic,  and 

Orthotic  Albuminuria    492 

Pathological  Albuminuria 497 

Tests   500 

Test  by  Boiling  500 

Heller's  Test 502 

Test   by   Acetic   Acid    and    Potassic 

Ferrocyanide 502 

Heynsius's  Test  502 

The    Magnesium-nitric    Test    (Rob- 
erts's)   502 

Metaphosphoric  Acid  (Hindenlang's)  502 

Picric  Acid  Test   (Johnson's)    502 

Perchloride-of-mercury   or    Spiegler 

Test  502 

Millon's  Test   503 

Tanret's  Test  503 

Xanthoprotein  Test 503 

Transportable    Reagents    for    Albu- 
min     504 

Quantitative  Tests    505 

Miscellaneous   506 

Alcohol  507 

Preparations  and  Dose   507 

Modes  of  Administration  508 

Contraindications 510 

Physiological   Action    511 

Digestive  Tract   511 

Nervous  System    512 

Circulation 514 

Blood 515 

Respiration    516 

Secretions    517 

Temperature   517 

Metabolism 517 

Immunity   517 

Absorption  and  Elimination 519 

Role  of  Alcohol  in  Nutrition 520 


PAGE 

Alcohol,    Phj^siological    Action     (coii- 
tiniied). 

External  Action 524 

Therapeutics   525 

As  a  "Stimulant" 525 

As  a  Vasodilator 527 

As  a  Narcotic  and  Hypnotic 530 

As  a  Stomachic,  Antemetic,  etc.   .  . .   530 

As  a  Diuretic  532 

In  Phenol  Poisoning  532 

External  Uses 532 

Alcohol  Injections 536 

Neuralgia  and  Neuritis  536 

Laryngeal  Tuberculosis  537 

Tumors 538 

Alcoholic  Neuritis.     See  Neuritis. 

Alcoholism,  or  Alcohol  Inebriety 538 

Definition  538 

Toxicity  of  the  Alcohols  540 

Varieties 541 

Acute  Alcoholism  541 

Definition  541 

Svmptoms    541 

Differential  Diagnosis  543 

Pathology 544 

Treatment    545 

Chronic  Alcoholism   547 

Definition  547 

Symptoms    547 

Diagnosis   550 

Pathology 552 

Prognosis 552 

Treatment    553 

Home  Treatment 553 

Office  Treatment  554 

Hospital  Treatment 555 

General  Treatment  556 

Acute    Alcoholic    Delirium,    or    De- 
lirium Tremens   560 

Symptoms    560 

Diagnosis  561 

Pathology    561 

Prognosis  562 

Treatment 562 

Acute    Alcoholic    Mania    (Mania    a 

Potu)     565 

Symptoms    565 

Differential  Diagnosis   566 

Etiology  and  Pathology 566 

Prognosis 566 

Treatment    566 

Aleppo  Boil.     See  Oriental  Sore. 

Aloes  566 

Properties  and  Constituents   566 

Dose  and  Preparations  567 

Modes  of  Administration 568 

Incompatibles    568 

Contraindications 568 


CONTENTS. 


xin 


PAGE 

Aloes  (continued). 

Physiological   Action    568 

Untoward  Effects   569 

Therapeutic  Uses 569 

As  a  Laxative 569 

As  a  Stomachic  570 

As  an  Emmenagogue  570 

In  Hemorrhoids 570 

Alopecia   570 

Definition  570 

Congenital  Alopecia   571 

Senile  Alopecia 572 

Premature  Alopecia   572 

Alopecia  Seborrhoeica    573 

Etiology  and  Pathology   573 

Prognosis 575 

Treatment    575 

Alopecia  Areata  577 

Definition  577 

Symptoms    577 

Etiology    578 

Pathology    580 

Prognosis 580 

Treatment    580 

Phototherapy    582 

Alsol.     See  Aluminum  :    Aluminum  Ace- 
totartrate. 

Alum  582 

Dose    582 

Modes  of  Administration  582 

Incompatibles    583 

Contraindications    583 

Physiological  Action    583 

Untoward  Effects  and  Poisoning 583 

Therapeutic  Uses 584 

As  an  Astringent 584 

As  a  Caustic  585 

As  an  Emictic  585 

As  a  Stimulant  to  Peristalsis 585 

Aluminum    586 

Aluminum  Hydroxide  587 

Aluminum    Sulphate    587 

Aluminum  Acetate   587 

Aluminum  Acetotartrate  (Alsol)   588 

Aluminum    Borof ormate 589 

Aluminum  Borotannate   (Cutal)    589 

Aluminum  Borotartrate  (Boral)    589 

Aluminum  Carbonate 589 

Aluminum  Chloride   590 

Aluminum  Phenolsulphonate 590 

Aluminum  Salicylate    590 

Aluminum  Silicate   590 

Alumnol 590 

Mode  of  Employment '. 590 

Therapeutic  Uses 590 

Amaurosis   592 

Definition  592 

Amaurosis  in  Brain  Disease  592 


PAGE 

Amaurosis,  Definition  (continued). 

Amaurosis  in  Nephritis 592 

Amaurosis  in  Hysteria   593 

Amaurosis  in  Spinal  Disease 593 

Amaurosis  Following  Hemorrhage  .  594 

Amaurosis  in  Pregnancy   594 

Amaurosis    from    Fracture    of    the 

Skull    595 

Congenital    and    Hereditary    Amau- 
rosis    595 

Amblyopia   596 

Definition  596 

Amblyopia  from  Intracranial  Causes.  597 

Hysterical  Amblyopia 598 

Simulated  Amblyopia 598 

Amblyopia  Exanopsia   599 

Amblyopia  from  Exhaustion 600 

Amenorrhea    600 

Definition  600 

Varieties     600 

Symptoms    600 

Etiology 601 

Nervous  Disorders  601 

General  Affections    602 

Blood  Disorders  and  Wasting  Dis- 
eases      602 

Lesion  of  Genitourinary  Organs  . . .  603 

Pathology    604 

Diagnosis  604 

Prognosis  604 

Treatment    604 

Aminoform.     See  Hexamethylenamine. 
Amidoacetphenetidin  Hydrochloride.   See 
Phenocoll  Hydrochloride. 

Ammonia  606 

Properties    606 

Preparations  and  Dose  607 

Modes  of  Administration  607 

Incompatibles    608 

Contraindications 608 

Physiological  Action 608 

Local  Effects    608 

Eft'ects  on  Internal  Use 608 

Toxicology    609 

Treatment  of  Ammonia  Poisoning  .  610 

Therapeutic  Uses   610 

As  a  Stimulant 610 

As  an  Antacid  611 

As  a  Counterirritant,  Rubefacient,  or 

Cauterant 611 

Ammonium    612 

Physiological  Action 613 

Ammonium  Acetate  614 

Mode  of  Administration  614 

.    Incompatibles    614 

Physiological  Action 614 

Therapeutics   615 

As  a  Diaphoretic  and  Diuretic  . . .  615 


XIV 


CONTENTS. 


PAGE 

Ammonium   (continued). 

Ammonium   Carbonate    615 

Modes  of  Administration  616 

Incompatibles    616 

Physiological  Action 616 

Toxicology •  •   617 

Therapeutics   617 

As  an  Expectorant  617 

As  a  Stimulant    617 

As  a  Gastric  Stimulant  or  Emetic  .   617 
As  a  Rubefacient  and  Discutient  .   617 

Ammonium  Chloride   617 

Mode  of  Administration   618 

Incompatibles    618 

Physiological  Action    618 

Therapeutics   619 

As  a  Stimulant  to  Mucous  Mem- 
branes     619 

In  Aural  Disorders   620 

In  Gastric  Catarrh  620 

In  Cystitis  620 

As  a  Stimulant  to  the  Liver 620 

In  Alcoholism    620 

In  Neuralgia  and  Migraine  620 

External  Uses    621 

Ammonium    Ichthyol    Group.      See   Ich- 

thyol. 
Amputations   and   Resections.      See   Re- 
sections, Amputations,  etc. 
Amyl  Nitrite.     See  Nitrites. 
Amylene  Chloral.    See  Dormiol. 

Amylene  Hydrate  621 

Dose  and  Modes  of  Administration  . .  621 

Physiological  Action    621 

Untoward  Effects ;  Poisoning 622 

Therapeutic  Uses 622 

Amyloform    623 

Physiological  Action    623 

Therapeutic  Uses 623 

Amyl  Valerate  624 

Physiological  Action   624 

Therapeutic  Uses 624 

Analgen    624 

Physiological  Action 624 

Therapeutic  Uses    ■. .  625 

Anemia.     See  Anemia,  Secondary. 

Anemia,  Pernicious  Progressive   625 

Definition  625 

Symptomatology    625 

Blood   Examination    627 

Pathology 630 

Diagnosis  636 

Etiology   638 

Prognosis  639 

Treatment    641 

Anemia,  Secondary,  or  Symptomatic   . . .   646 

Definition  646 

Types  of  Secondary  Anemia 646 


PAGE 

Anemia,    Types    of    Secondary     (con- 
tinued). 

Posthemorrhagic  Anemias   646 

Infectious  and  Toxic  Anemias 647 

Trophic  Anemias 648 

Pathology 649 

Symptomatology    653 

Diagnosis  657 

Prognosis 659 

Treatment    659 

Anemia,  Splenic.    '  See  Spleen,  Diseases  of. 
Anesin.     See  Chloretone. 
Anesthesia.      See    Various    Anesthetics : 
Ether,  Chloroform,  etc. 

Anesthesin  664 

Physiological  Action 664 

Therapeutic  Uses   664 

Aneurism   665 

Definition  665 

Varieties 665 

Congenital 665 

Idiopathic 665 

Traumatic    665 

Hernial   665 

True 665 

False   665 

Difl-use    665 

Dissecting    665 

Embolic    665 

Miliary    666 

Fusiform   or  Ectatic    666 

Sacculated   666 

Etiology   666 

Pathology 668 

Symptoms    670 

Course    674 

Differential  Diagnosis 674 

Treatment    675 

Arterial  Compression 677 

Forced  Flexion 677 

Arterial  Ligature 677 

Dix's  Operation  678 

Excision  of  the   Sac  and  Implanta- 
tion      679 

Reinoval  or  Obliteration  of  the  Sac  .  679 
Obliterative  Method  of  Matas  ...  679 
Matas's    Conservative    Endoaneu- 

rismorrhaphy 680 

Macewen's  Acupuncture  681 

Electrolysis    681 

Moore's  Method   681 

Moore-Corrady's  Method 681 

Arteriovenous  Aneurism 683 

Aneurismal  Varix 683 

Varicose  Aneurism 683 

Symptoms    683 

Treatment    683 

Conditions  Related  to  Aneurisms 684 


CONTENTS. 


XV 


PAGE 

Angina  Ludovici.     See  Pharynx. 

Angina    Pectoris    684 

Defmition  684 

Symptoms    684 

Diagnosis   686 

Etiology    689 

Pathology 690 

Prognosis 694 

Treatment    695 

Angiomata.     See  Blood-vessels,  Tumors 

of   698 

Angioneurotic  Edema.     See  Ascites  and 

Edema    698 

Anhalonium   Lewinii    698 

Preparations  and  Dose 699 

Physiological  Action   , .  699 

Therapeutic  Uses 699 

Anhidrosis.    See  Sweat  Glands.  Diseases 

of 700 

Anidrosis.     See   Sweat  Glands,   Diseases 

of. 
Animal  Extracts,  or  Organotherapy  ....   700 

Thyroid  Gland  Organotherapy 700 

Physiological  Action 701 

Action  on  Metabolism   701 

The  Thyroparathyroid  Secretion  as 

Opsonin    704 

The  Active  Principle  of  Thyroid  . . .  707 

Preparations  and  Dose  708 

Untoward  Effects  and  Their  Preven- 
tion    709 

Treatment  of  Thyroid  Poisoning   . .   709 

Therapeutics   710 

Hypothyroidia,     or     Hypothyroid- 
ism      711 

Hyperthyroidia,   or   Hyperthyroid- 
ism      715 

Cretinism   717 

Danger  Signals   721 

Myxedema  723 

Contraindications    725 

Obesity   1TJ 

Contraindications 728 

Miscellaneous  Disorders  729 

Acromegaly 729 

Arteriosclerosis    730 

Arthritis,  Chronic  Rheumatoid  .   730 

Cancer 732 

Cutaneous  Disorders   734 

Exophthalmic  Goiter   735 

Goiter    Til 

Hemophilia 738 

Incontinence  of  Urine  738 

Infectious  Diseases 739 

Insanity 741 

Lactation    744 


PAGE 

Animal    Extracts,   Therapeutics,    Mis- 
cellaneous Disorders    (continued). 

Middle-ear  Disorders 744 

Nervous  Disorders   744 

Epilepsy    744 

Eclampsia 746 

Migraine 747 

Asthma  748 

Tetanus    748 

Osseous  Disorders 748 

Rheumatism,  Chronic  Progress- 
ive      749 

Uterine  Disorders  750 

Summary   751 

Parathyroid   Organotherapy    752 

Therapeutics   753 

Adrenal,    or    Suprarenal,    Organother- 
apy     755 

Physiological  Action    756 

Physiology  of  Local  Action 757 

Preparations  and  Dose   758 

Untoward  Effects   759 

Therapeutics 763 

Addison's  Disease  763 

Shock,  Collapse,  and  Surgical  Dis- 
eases      764 

Toxemias     and     Bacterial     Infec- 
tions    766 

Postoperative  Intestinal  Atony  . . .   768 

Miscellaneous  Disorders  769 

Hemorrhage    769 

Sthenic  Cardiac  Disorders 770 

Asthma  770 

Effusions    770 

Disorders     of     Pregnancy     and 

Parturition 770 

Cancer 771 

Osteomalacia 772 

Local  Use 773 

Hemorrhage    773 

Hemorrhoids 773 

Neuralgia,    Sciatica,    and    Neu- 
ritis      774 

Cutaneous  Disorders   774 

Pituitary  Organotherapy 774 

Preparations  and  Dose  776 

Therapeutics   777 

Acromegaly  777 

Cardiac   Disorders    777 

Obstetrics 778 

Infectious  Diseases 780 

Exophthalmic  Goiter   781 

Nervous  and  Mental  Diseases  and 

Myopathies    781 

Stunted  Growth  and  Imbecility  . . .  782 


XVi 


CONTENTS. 


Pituitary  Organotherapy,  Therapeutics 
(continued). 

Intestinal  Paresis    782 

Orchitic,    or    Testicular,    Organother- 
apy ;  Spermin  783 

Therapeutics   785 

Ovarian   Organotherapy   786 

Preparations   and   Dose    787 

Therapeutics   787 

Natural  and  Artificial  Menopause.   787 

Corpus  Luteum  Organotherapy  788 

Preparations  and  Dose   789 

Therapeutics   789 

Natural  and  Postoperative  Meno- 
pause and  Disorders  of 
Pregnancy    789 


Pituitary  Organotherapy    (continued) . 

Kidney  Organotherapy   790 

Therapeutics  and  Dose  791 

Thymus  Organotherapy   792 

Therapeutics   792 

Diseases  of  the  Thyroid  792 

Rachitis,  or  Rickets  792 

Bone-marrowr  Organotherapy  793 

Brain   and   Nerve    Substance    Organo- 
therapy       794 

Mammary  Gland  Organotherapy 794 

Spleen  Organotherapy  795 

Hepatic  Organotherapy 795 

Bile,  Bile-salts,  and  Biliary  Extracts   .   797 
Hormones    799 


SAJOUS'S 
ANALYTIC    CYCLOPEDIA 
of  PRACTICAL  MEDICINE 


ABDOMEN,   SURGERY   OF  — 

Abdominal  surgery  in  its  wide  sense 
includes  a  great  variety  of  operative 
procedures  which  are  based  upon  the 
same  general  principles  as  the  ones 
which  are  included  in  this  article,  but 
which  have  been  left  to  contributors 
in  the  other  departments:  all  of  the 
external  hernias,  a  good  part  of  renal 
surgery,  the  surgery  of  the  abdominal 
walls,  and  all  of  the  pelvic  surgery  of 
the  female. 

This  article  takes  account  of  that 
part  of  abdominal  surgery  which  in- 
cludes hollow  and  solid  viscera,  the 
former  comprising  the  various  parts 
of  the  alimentary  tube  between  the 
diaphragm  and  the  brim  of  the  pelvis, 
all  biliary  and  pancreatic  ducts  and 
the  gall-bladder.  The  solid  viscera 
belonging  to  this  series  of  articles 
comprise  the  liver,  spleen  and  pan- 
creas only. 

There  is  a  general  sameness  of  the 
alimentary  canal  in  these  various 
parts  which  leads  to  more  or  less 
correspondence  between  operations 
done  at  the  different  levels  of  this 
tract.  Operations  of  the  biliary  ducts 
and  gall-bladder  also  have  many 
points  in  common,  and  they  resemble 
in  a  way  the  operative  resources  that 


are    employed   for   the   genitourinary 
passages. 

We  propose  to  consider  the  spe- 
cial features  of  abdominal  surgery  in 
two  ways :  first,  as  a  series  of  typical 
operations  which  are  intended  to  cor- 
rect certain  diseased  states,  and  then 
from  the  other  direction  as  a  series  of 
diseased  states  to  be  relieved  by 
operative  procedures  of  various  kinds. 
It  seems  therefore  of  advantage  to 
consider  the  typical  operations  for  the 
stomach,  small  and  large  intestines  and 
biliary  passages  as  operations  which 
are  in  a  way  applicable  to  all  surgical 
conditions  of  these  organs.  Surgical 
diseases  of  the  peritoneum,  appendix, 
liver,  spleen  and  pancreas  require 
separate  consideration  in  detail,  be- 
cause of  the  relative  absence  of  typi- 
cal operations,  making  the  treatment 
more  or  less  individualized  for  each 
case. 

THE  FOURTH  ERA  IN  SUR- 
GERY.— In  abdominal  surgery  we 
have  perhaps  the  best  field  for  object 
lessons  relative  to  the  new  fourth  or 
physiologic  era  in  surgery.  The  first 
era  in  surgery  was  the  heroic,  under 
which  practically  no  abdominal  sur- 
gery was  done.  In  the  second  or 
anatomic   era   of  surgery,  abdominal 


ABDOMEN,    SURGERY   OF    (MORRIS). 


operations  were  in  general  so  danger- 
ous that  few  were  attempted,  except- 
ing in  cases  of  great  emergency,  and 
usually  with  a  fatal  ending.  The 
third  or  pathologic  era  of  surgery  was 
based  upon  the  studies  of  Pasteur  and 
of  Lister.  Aside  from  its  technique 
of  preventing  the  development  of  bac- 
teria in  wounds,  it  included  the  idea 
of  removing  all  products  of  infection 
with  painstaking  care. 

Notwithstanding  the  injury  that 
was  done  to  patients  by  surgeons 
carrying  out  the  principles  of  this  era, 
abdominal  surgery  made  its  first  great 
advances.  Detailed  attention  was 
given  to  the  deliberate  disposal  of 
products  of  infection  found  within  the 
peritoneal  cavity,  and  little  or  no  at- 
tention was  paid  to  the  natural  re- 
sistance forces  contained  within  the 
patient  himself.  There  was  an  enor- 
mous waste  of  such  forces,  in  fact,  in 
our  abdominal  surgery  of  the  patho- 
logic era. 

The  entirely  modern  or  physiologic 
era  is  based  upon  the  studies  of 
Metchnikofif  and  Wright,  and  includes 
the  principal  idea  of  allowing  the 
patient  to  retain  his  natural  forces 
in  such  a  way  as  to  gain  control  of 
infections.  Metchnikofif  and  his  fol- 
lowers taught  us  that  certain  cells  of 
the  blood  and  lymph  circulatory  sys- 
tems not  only  disposed  of  bacteria 
daily  under  normal  conditions,  but 
that  these  cells  were  increased  in 
number  rapidly  to  meet  emergen- 
cies of  infection.  These  investigators 
showed  also  that  bacteria  were  de- 
stroyed by  certain  fixed  body  cells. 
Wright  and  his  followers  showed  fur- 
ther that,  in  the  presence  of  an  infec- 
tion, several  kinds  of  antibodies  were 
elaborated  in  the  animal  economy, 
and  these  antibodies  lent  their  aid  in 


removing  infections  and  in  destroy- 
ing certain  toxins  that  were  produced 
by  bacteria.  The  principles  of  this 
fourth  or  physiologic  era  of  surgery 
brought  us  face  to  face  with  the 
problem  of  operating  in  such  a  way 
as  to  leave  the  patient  in  the  very 
best  condition  for  managing  infec- 
tions himself  with  his  own  phagocytes 
and  antibodies,  and  led  to  a  revolu- 
tion in  methods,  forcing  us  to  drop 
out  of  our  technique  such  parts  of  the 
system  of  the  third  or  pathologic  era 
as  interfered  with  the  ability  of  the 
patient  to  produce  phagocytes  and 
antibodies. 

For  instance,  a  prolonged  and 
painstaking  operation  for  removing 
all  of  the  pus  from  the  peritoneal 
cavity  so  shocked  the  great  vaso- 
motor centers  of  the  patient  that  they 
were  palsied,  and  unable  promptly  to 
take  up  the  work  of  conducting  the 
manufacture  of  phagocytes  and  anti- 
bodies, with  which  the  patient  him- 
self could  dispose  of  the  products  of 
infection  much  better  than  the  sur- 
geon could  do  it  in  his  crude  mechani- 
cal way. 

Unnecessarily  prolonged  operations 
acted  in  precisely  the  same  way; 
and  where  we  had  thought  best  to 
expend  a  half-hour  in  carrying  out 
the  theories  of  the  pathologic  era  in 
surgery,  we  may  now  expend  five 
minutes  under  the  principles  of  the 
physiologic  era. 

Shock  is  producea  more  readily  by 
manipulation  of  the  abdominal  viscera 
than  by  gross  injuries,  when  animals 
are  fully  anesthetized,  especially  when 
the  anesthetic  used  is  chloroform.  The 
parietal  peritoneum  and  the  peritoneal 
mesenteries  are  especially  sensitive 
to  shock  under  manipulation.  Mam- 
mery  and  Symes  (Brit.  Med.  Jour., 
vol.  ii,  p.  790,  1908). 


ABDOMEN,   SURGERY   OF    (MORRIS). 


A  long  period  of  anesthesia  was 
commonly  required  for  tlioroui;li  work 
under  the  prineiples  of  the  third  era, 
but  we  now  know,  from  our  experi- 
ments upon  animals,  that  individuals 
profoundly  under  the  influence  of 
alcohol,  or  of  ether  or  of  chloroform, 
temporarily  lose  resistance  to  infec- 
tions, and  some  acute  infections  which 
would  not  gain  headway  under  a  few- 
minutes  of  anesthesia  may  seize  the 
opportunity  to  gain  ascendancy  if  the 
anesthesia  is  prolonged  for  an  hour  or 
two.  Bulky  or  complicated  drainage 
apparatus,  acting  as  a  foreign  body, 
further  produce  derangement  of  func- 
tion of  the  vasomotors  in  such  a  way 
as  to  prevent  the  patient  from  manu- 
facturing his  phagoc3^tes  and  anti- 
bodies. We  are  just  entering,  then, 
the  era  in  which  the  greatest  degree 
of  success  is  to  follow  our  opera- 
tive procedures  within  the  abdominal 
cavity. 

ANTEOPERATIVE  MANAGE- 
MENT.— Aside  from  the  general  prin- 
ciples which  govern  the  preparation 
of  a  patient  for  any  major  operation, 
certain  special  requirements  are  indi- 
cated which  lessen  the  operative  risk, 
and  the  tendency  to  postoperative 
complications   in   abdominal   surger}^ 

Postoperative  pneumonia,  for  in- 
stance, will  occur  less  often  if  we 
make  careful  choice  of  the  anesthetic 
for  any  given  case,  and  if  we  make 
this  period  of  anesthesia  as  short  as 
possible,  on  account  of  the  known 
tendency  of  some  acute  infections  to 
shoot  ahead  when  the  patient  is  under 
the  influence  of  ether  or  chloroform. 
Some  operators  will  choose  nitrous 
oxide  and  oxygen  in  cases  in  which 
this  phenomenon  is  anticipated.  In 
some  feeble  patients,  or  patients  with 
complications     of     disease     of     vital 


organs,  spinal  anesthesia  according  to 
the  Jonncsco  method   is  dcsiraljle. 

Preoperative  intestinal  asepsis  can 
only  be  approximated,  but  for  most 
practical  purposes  a  good  purgative 
given  within  twenty-four  hours  of 
operation  will  suffice.  If  the  stomach 
itself  is  to  be  operated  upon,  further 
steps  in  the  direction  of  asepsis  are 
required,  and  we  wash  the  stomach 
out  very  thoroughly  with  saturated 
boric  acid  solution  just  in  advance  of 
operation.  This  is  done  most  comfort- 
ably, as  a  rule,  after  the  patient  is 
under  the  influence  of  the  anesthetic, 
and  by  means  of  the  common  siphon 
tube.  After  the  alimentary  tract  has 
been  cleansed  by  purgatives,  it  is  im- 
portant to  give  only  the  simplest  arti- 
cles of  food  and  drink  in  advance  of 
the  operation,  but  we  must  avoid  hav- 
ing a  patient  abstain  in  such  a  way 
as  to  become  unduly  weakened.  Pa- 
tients who  are  accustomed  to  dieting 
may  sometimes  be  placed  on  special 
diet  to  advantage  for  a  few  days  in 
advance  of  operation,  but  the  physical 
effect  of  placing  a  patient  on  diet  for 
any  length  of  time  is  apt  to  be  such 
as  to  counteract  any  good  effect. 

In  general  a  short  period  of  rest  in 
bed  before  an  operation  is  of  advan- 
tage, but  if  this  time  extends  beyond 
twenty-four  hours,  excepting  for 
patients  who  are  already  in  bed  with 
some  severe  abdominal  complication, 
the  apprehension  and  introspection  of 
the  patient  with  a  negative  imagina- 
tion, in  advance  of  operative  proced- 
ures may  be  disastrous,  and  has  even 
gone  to  the  point  of  allowing  the 
patient  to  develop  suicidal  impulse. 
For  patients  who  are  not  already  in 
bed  from  necessity,  the  author  pre- 
fers to  have  as  short  a  period  of  prep- 
aration as  expediency  would  suggest, 


ABDOMEN,   SURGERY   OF    (MORRIS). 


not  more  than  twenty-four  hours  as 
a  rule.  There  are  many  instances 
in  which  the  patient  needs  special 
medical  treatment  in  advance  of  opera- 
tion, because  of  some  defect  of  the 
heart,  lungs,  or  kidneys,  but  under 
such  circumstances  with  most  patients 
it  is  best  not  to  tell  them  of  the  date 
set  for  operation  far  in  advance,  up  to 
which  they  are  to  be  led. 

Anteoperative  narcosis  is  undesir- 
able for  one  chief  reason  shown  by 
Cantacuzene  in  his  experiments  with 
animals  subjected  to  the  influence  of 
opium  after  infection.  This  author 
showed  that  narcotized  animals 
rapidly  succumbed  at  the  time  when 
another  series  subjected  to  the  same 
infection,  but  not  narcotized,  were 
meeting  the  infection.  Arrangements 
Ishould  be  made  in  advance  of  opera- 
tion for  maintaining  the  animal 
warmth  of  the  patient  with  woolen 
garments  or  blankets,  and  it  is  best 
to  have  a  good  circulation  of  air  in 
the  operating  room.  In  an  OA^er- 
heated  operating  room  with  closed 
windows  and  doors  the  surgeon  him- 
self may  be  extremely  uncomfortable, 
and  feeling  the  need  for  oxygen,  and 
we  assume  that  the  patient  at  the 
same  time  suffers  the  same  depressing 
influence  in  addition  to  the  shock 
of  the  operation.  Experiments  with 
animals  have  shown  that  the  perito- 
neum is  not  injured  by  exposure  to 
air  currents  and  to  Ioav  temperature  as 
much  as  it  is  injured  by  contact  with 
.gauze  antiseptic  solutions,  or  by  rough 
handling.  The  author  believes  that 
the  temperature  and  air  circulation  of 
the  room  most  agreeable  to  the  sur- 
geon is  at  the  same  time  most  benefi- 
cial to  the  patient.  x\sepsis  is  to  be 
begun  where  possible  before  the 
operation   with   a    general   bath,    and 


particular  attention  given  to  the  prep- 
aration of  the  umbilical  region. 

The  skin  in  the  field  of  operation 
may  be  well  prepared  in  the  common 
way  by  shaving,  then  scrubbing  with 
green  soap,  which  is  washed  off  with 
a  weak  bichloride  of  mercury  solution, 
and  a  pad  of  gauze  wet  with  this  solu- 
tion is  placed  in  contact  with  the 
wound  for  a  few  hours.  A  recently 
introduced  and  A^ery  effective  way  of 
sterilizing  the  skin  consists  in  simply 
painting  it  over  with  a  2  per  cent,  solu- 
tion of  iodine  in  benzin  after  shaving. 

The  need  of  aseptic  surroundings 
relating  to  the  preparation  of  the 
operating  room  need  not  be  discussed 
in  this  article.  Asepsis  on  the  part  of 
the  operator  is  met  by  the  wearing  of 
a  sterile  gown  and  cap  and  a  mouth 
guard  of  gauze,  because  with  every 
breath,  and  particularly  in  the  course 
of  conversation  during  an  operation, 
bacteria  are  projected  from  the  mouth 
of  the  operator  OA^er  the  field  of  the 
Avound. 

The  hands  and  forearms  may  be 
prepared  simply  by  scrubbing  with 
green  soap,  and  then  in  a  Aveak  solu- 
tion of  bichloride  of  mercury.  This 
destroys  practically  all  of  the  bacteria 
AA'hich  are  likely  to  cause  trouble. 
Latent  colonies  of  bacteria  AAdiich 
work  out  of  the  •  epithelium  of  the 
hands  in  the  course  of  an  operation 
are  generally  dormant  colonies  Avhich 
are  managed  by  the  blood-serum  or 
tissues  of  the  patient  safely.  The  use 
of  rubber  gloves  in  abdominal  sur- 
gery is  particularly  undesirable ;  first 
because  they  interfere  Avith  the  nice 
sense  of  touch  required  for  separating 
adhesions,  or  for  doing  rapid  sutur- 
ing. The  operator  wearing  rubber 
gloves  is  apt  to  require  longer  inci- 
sions Avhich   alloAV   him  to  Avork  by 


ABDOMEN,   SURGERY   OF    (MORRIS). 


5 


sight,  and  this  is  not  in  harmony  with 
the  principles  of  the  ph}siokigic  era 
in  surgery. 

The  peritoneum  protects  itself  so 
well  if  given  fair  opportunity  that  we 
do  not  need  to  apply  the  extreme 
degree  of  asepsis  that  would  he 
needed  in  opening  the  knee-joint  or 
the  meninges  of  the  brain,  but  it  is 
well  for  assistants  Avho  are  not 
engaged  in  separating  adhesions,  or 
in  applying-  sutures,  or  in  hunting  for 
structures  within  the  abdomen,  to 
wear  rubber  gloves.  One  can  do  a 
much  higher  class  of  operative  work 
Avithin  the  peritoneal  cavity  where 
nice  sense  of  touch  is  not  interfered 
with ;  and  the  greater  length  of  time 
required  in  operating  where  rubber 
gloves  are  used  and  the  longer  inci- 
sions counterbalance  the  benefit  of 
such  asepsis  as  would  be  gained 
through  the  use  of  the  gloves. 

In  more  than  half  of  the  cases  of 
chronic  suppuration  in  the  pelvis  the 
pus  is  sterile  at  the  time  of  operation, 
showing  that  sterilization  of  the  in- 
fected focus  takes  place  automatically 
within  a  reasonable  time  in  the  major- 
ity of  cases.  H.  S.  Crossen  (Surg., 
Gynec,  and  Obstet.,  Oct.,  1909). 

It  has  been  shown  experimentally 
with  Petri  plates  in  the  operating 
room  that  large  numbers  of  bacteria 
are  constantly  falling  into  every  open 
wound,  no  matter  what  precautions 
have  been  observed  in  advance. 
These  bacteria  are  for  the  most  part 
disposed  of  in  the  patient's  tissues 
and  blood-  and  lymph-vessels  ;  but  the 
longer  the  incision  and  the  greater 
the  length  of  time  during  which  any 
given  wound  remains  open,  the  more 
bacteria  fall  into  the  w^ound  from  the 
air. 

If  one  can  work  more  quickly 
and    through    shorter   incisions    with 


bare  hands,  he  naturally  makes  better 
asepsis  of  the  wound,  provided  that 
his  hands  have  been  well  prepared  in 
advance. 

The  recent  reawakening  of  iodine 
disinfection  of  the  surface  in  abdominal 
surgery  is  fraught  with  danger.  In 
animal  experiments  (rabbits),  very 
small  amounts  of  iodine  injected  intra- 
peritoneally  will  produce  in  a  short 
time  abundant  layers  of  fibrin  and  firm 
membranes  and  bands  between  the  in- 
testines. The  effect  is  to  a  certain 
degree  specific,  in  contrast  to  that  of 
turpentine.  The  writer  injected  intra- 
peritoneally  in  a  dog  20  drops  of  the 
tincture  of  iodine,  dissolved  in  80  c.c. 
sterile  saline  solution,  and  found  after 
forty-eight  hours,  in  the  region  of  the 
liver  and  stomach,  abundant  fibrous  ad- 
hesions. There  were  no  adhesions  iii 
the  region  of  the  small  intestine.  The 
abdominal  cavity  in  the  human  subject, 
on  the  other  hand,  inclines  especially  to 
adhesions,  particularly  from  a  moder- 
ately specific  irritation,  as  from  gonor- 
rheal infection.  The  writer  has,  siirce 
the  introduction  of  iodine  disinfection, 
in  about  70  cases  of  appendicitis,  simple 
or  complicated  with  abscess  or  peri- 
tonitis, 6  times  found  ileus  from  kink- 
ing or  adhesions.  This  was  unusual 
before  the  use  of  iodine  for  this  pur- 
pose. Of  about  300  cases  of  appen- 
dicitis in  1910  and  1911,  before  the  in- 
troduction of  iodine  disinfection,  there 
were  only  5  cases  of  mechanical  intes- 
tinal obstruction.  He  concludes  that 
eventration  of  the  intestines  directly 
upon  the  browned  skin  should  be  ab- 
solutely avoided.  They  should  be  laid 
on  interposed  layers  of  gauze  moist 
with  saline  solution.  Whether  this  will 
be  sufficient  to  prevent  harmful  effects 
from  the  iodine  must  be  determined  by 
further  observations.  Propping  (Zen- 
tralbl.  f.  Chir.,  Bd.  xxxviii,  S.  661, 
1911). 

Instruments  may  be  sterilized  by 
dry  heat  in  the  oven,  by  immersion  in 
95  per  cent,  carbolic  acid,  or  in  the 
more  common  wa)^  by  boiling  in 
water    for    fifteen    minutes,      In    the 


ABDOMEN,    SURGERY   OF    (MORRIS). 


later  case  bicarbonate  of  soda  in  the 
proportion  of  a  teaspoonful  to  a  quart 
of  water  is  added  to  prevent  the  rust- 
ing of  instruments.  The  carbolic  acid 
preparation  is  particularly  suitable  for 
small,  sharp,  delicate  instruments, 
and  does  not  interfere  in  any  way 
with  their  edges.  The  carbolic  acid 
^^'hich  clings  to  them  on  removal  is 
instantly  neutralized  by  immersion  in 
alcohol. 

INSTRUMENTS  AND  APPA- 
RATUS.— Scissors. — There  are  very 
few  intra-abdominal  operations  which 
cannot  be  performed  from  first  to  last 
with  a  pair  of  scissors  and  a  couple 
of  needles  and  no  other  instruments 
whatsoever.  In  adding  other  instru- 
ments which  give  special  facility  in 
certain  operations  it  is  well  to  remem- 
ber this  statement,  and  it  will  avoid 
the  multiplicity  of  instruments  which 
are  frequently  used  to  the  patient's 
disadvantage  or  injury,  as  may  be 
observed  often  enough.  The  form  of 
scissors  which  the  author  prefers  is 
the  ordinaiy  French  locked  type,  five 
or  six  inches  long,  with  one  sharp 
point  and  one  blunt  point,  and  kept 
very  sharp.  The  preference  for  scis- 
sors over  scalpel  is  based  upon  the 
fact  that  small  blood-vessels  seem  to 
ooze  much  less  after  division  with  the 
scissors  than  with  the  scalpel.  This 
is  possibly  due  to  contraction  stimu- 
lated by  the  character  of  the  cut  made 
by  the  scissors,  but  there  is  no  inter- 
ference with  primary  union  of  the 
tissues  subsequently,  according  to  ob- 
servations extended  over  a  series  of 
years. 

Needles  of  the  Hagedorn  t3^pe  will 
suffice  for  practically  all  abdominal 
work,  and  needles  threaded  with  cat- 
gut slipDed  under  bleeding  vessels 
readily  take  the  place  of  the  artery 


forceps  without  loss  of  time,  with  a 
rather  greater  degree  of  accuracy, 
and  with  less  crushing  of  tissues. 
For  intestinal  or  gastric  suturing  the 
author  prefers  a  needle  that  is  con- 
siderably larger  than  the  one  that  is 
commonly  used,  for  the  reason  that  it 
carries  a  suture  of  greater  diameter, 
and  a  suture  of  fairly  large  diameter 
does  not  cut  out  of  the  tissues  so 
readily  as  an  extremely  fine  suture 
when  subjected  to  tension.  The 
custom  of  using  a  very  fine  needle 
and  silk  is  based  upon  the  idea  of 
causing  the  least  degree  of  operative 
damage  and  avoidance  of  leaking  of 
contents  of  the  hollow  viscera,  but  it 
is  not  based  upon  our  observations  of 
the  extent  to  which  the  mucous  mem- 
brane will  plug  fairly  large  punctures, 
or  our  knowledge  of  the  greater  secu- 
rity of  tissues  sutured  with  a  strand 
large  enough  to  bind  without  cutting. 
Retaining  Apparatus. — The  author 
is  in  favor  of  depending  upon  his 
fingers,  and  those  of  assistants,  rather 
than  upon  clamps  and  other  retaining 
apparatus  in  abdominal  work;  but 
this  is  because  his  methods  were  ac- 
quired while  many  of  the  proficient 
clamps  which  facilitate  these  proced- 
ures were  in  the  course  of  develop- 
ment, and  which  gave  mechanical 
advantages  which  seemed  attractive, 
but  which  were  sometimes  observed 
to  be  injurious.  Rubber-covered 
clamps  of  various  forms,  if  carefully 
used,  allow  one  to  work  speedily. 
One  may  not  make  such  accurate  ad- 
justments or  such  regular  insertion  of 
sutures  if  he  disposes  of  mechanical 
adjuncts,  and  yet  in  cases  where  he 
can  work  quite  as  quickly  without 
them  the  balance  of  advantage  is  in 
favor  of  the  gentler  method.  Tem- 
porary steadying  sutures  may  some- 


ABDOMEN,    SURGERY   OF    (MORRIS). 


7 


times  be  employed  in  addition  to  the 
lingers  in  order  to  maintain  a  viscus 
in  a  certain  position  while  operation 
is  being-  performed,  and  these  are 
liable  to  do  less  harm  than  steel 
instruments  in  the  peritoneal  cavity. 
The  author  has  employed  most  of  the 
mechanical  devices  described  for  facil- 
itating operative  work  upon  the 
stomach  and  bovv^el,  but  has  dropped 
most  of  them,  excepting  the  Murphy 
button,  in  favor  of  simple  methods  of 
suturing-,  and  the  button  is  not  used 
nearly  as  often  now  as  it  was  a  few 
years  ago. 

Drainage  tubes  for  the  most  part 
should  be  small,  as  otherwise  they 
pla}^  the  part  of  a  foreign  body  in  the 
abdominal  cavity,  and  this  is  resented 
by  the  peritoneum.  In  1895  the 
author  described,  in  his  book  on  the 
subject  of  appendicitis,  a  drainage 
wick  which  would  take  the  place  of 
drainage  tubes  in  most  places  in  the 
peritoneal  cavity,  and  which  would 
cause  very  little  offense  to  the  perito- 
neum. It  consisted  of  gauze  rolled 
loosely  in  a  covering  of  gutta-percha 
or  of  rubber  dam,  very  much  as  one 
rolls  a  cigarette,  but  leaving  one  end 
of  gauze  protruding.  This  soft,  flexi- 
ble drainage  wick  acts  by  capillarity, 
adapts  itself  to  bends  and  angles,  and 
suffices  for  most  purposes  of  abdom- 
inal drainage,  provided  that  one 
understands  the  principles  of  capillary 
drainage,  and  keeps  a  good  mass  of 
fresh  gauze  upon  the  abdominal  wall 
in  such  a  way  as  to  maintain  the 
capillary  power  df  the  wick. 

Gauze  drains  not  protected  with  an 
inoffensive  covering  are  quickly  filled 
with  lymph-coagula  poured  out  from 
the  peritoneum  in  response  to  their 
irritating  presence,  and  they  become 
fastened  to  tissues  in  such  a  way  that 


on  removal  they  may  draw  loops  of 
bowel  into  angulation.  Where  a  very 
long  drain  is  required,  as  from  the 
cystic  duct  or  from  the  bottom  of  the 
pelvis,  the  same  principle  may  be  ap- 
plied by  using  an  ordinary  flexible- 
rubber  drainage  tube  or  catheter  split 
throughout  its  entire  length  on  one 
side,  and  the  wick  of  absorbent  gauze 
carried  loosely  through  the  lumen  of 
the  tube.  It  is  very  seldom  at  the 
present  time  that  one  will  need  to  use 
any  gauze  packing  in  the  peritoneum 
cavity;  but  if  such  a  calamity  does 
arise,  less  harm  is  done  if  the  gauze 
is  covered  with  an  apron  of  gutta- 
percha tissue  or  rubber  dam  to  keep 
the  bowel  from  becoming  adherent, 
thus  carrying  out  in  a  way  the  prin- 
ciple of  the  protected  drainage  wick. 
For  patients  with  very  heavy  abdom- 
inal walls  where  pressure  might  nearly 
close  the  wick  drain  with  its  cover  of 
rubber  dam,  or  of  rubber  tubing,  sheet 
lead  is  a  useful  part  of  our  apparatus. 
Sheet  lead  can  be  cut  with  the  scis- 
sors into  strips  of  any  desired  width 
or  length,  and  this  strip  doubled  upon 
itself  carries  between  the  two  arms  a 
drain  of  absorbent  gauze.  The  end  of 
lead  projecting  upon  the  external 
abdominal  wall  can  be  bent  over  to 
avoid  the  danger  of  the  drain  slipping 
within.  Lead  seems  to  be  quite  as 
benign  as  rubber  or  gutta-percha 
tissue,  and  is  accepted  kindly  by  the 
tissues,  excepting  where  it  projects 
to  some  distance  within  the  abdom- 
inal cavity,  in  which  latter  case  it 
presents  a  more  rigid  and  objection- 
able foreign  body. 

Suture  Materials. — The  choice  of 
suture  materials  in  abdominal  surgery 
is  extremely  important. 

For  ordinary  ligating  of  vessels, 
and   for  suturing  of  the  peritoneum 


ABDOMEN,    SURGERY   OF    (MORRIS). 


where  adhesions  are  to  be  avoided, 
very  simply  prepared  catgut  is  pref- 
erable, and  excepting  for  large  vessels 
a  catgut  which  would  be  absorbed  in 
forty-eight  hours  possesses  advan- 
tages, because  any  suture  material  for 
the  peritoneum  which  remains  for 
two  or  three  days  is  prone  to  cause, 
by  its  irritating  presence,  a  line  of 
peritoneal  lymph-exudate  followed  by 
annoying  adhesions.  This  is  in  ac- 
cordance with  the  well-known  action 
of  the  peritoneum  in  walling  in  any 
object  which  is  a  source  of  irrita- 
tion. While  such  adhesions  may  be 
absorbed  later,  and  may  not  be  in  a 
position  to  cause  much  annoyance, 
nevertheless  there  are  many  thou- 
sands of  patients  today  suffering  to 
some  degree  from  adhesions  of  the 
omentum  or  bowel  to  the  anterior 
abdominal  wall,  in  cases  where  this 
complication  could  have  been  entirely 
avoided  by  the  use  of  very  fine, 
quickly  absorbed  suture  material, 
which  would  not  have  caused  the 
pouring  out  of  much  lymph  by 
the  peritoneum.  Peritoneal  margins 
united  with  the  finest  of  sutures 
become  adherent  so  quickly  that  there 
is  no  real  need  for  any  suturing  which 
will  last  for  more  than  twenty-four 
hours  in  the  parietal  peritoneum  of 
the  abdominal  wall,  or  in  other  places 
where  strong  permanent  adhesions  are 
not  purposely  induced. 

For  suturing  the  cut  margins  of 
bowel  or  stomach  for  the  purpose 
of  preventing  hemorrhage,  and  of 
closing  of  tissues  against  infection, 
small  chromic  catgut  in  the  place  of 
simply  prepared  catgut  is  desirable, 
for  it  resists  digestion  when  in  con- 
tact with  the  secreting  glands  of 
these  organs  longer  than  simply  pre- 
pared catgut.     Simply  prepared  cat- 


gut, when  in  the  secreting  glands  of 
the  stomach  or  bowel,  may  be  lique- 
fied in  a  very  few  hours,  and  chromic 
catgut  in  this  position  will  do  no 
harm,  because  it  is  at  a  point  where 
adhesions  are  purposely  secured. 

Linen  thread  and  silk  are  used  in 
the  positions  where  we  wish  snug 
apposition  of  tissues  until  firm  adhe- 
sions have  been  formed,  or  cut  struc- 
tures of  the  stomach  or  bowel  have 
united.  For  closing  all  parts  of  the 
abdominal  wall  we  may  dispose  of 
any  suture  material,  excepting  the 
very  fine,  simply  prepared  catgut  for 
the  peritoneal  layer  and  skin,  and 
chromic  catgut  for  the  anterior  and 
posterior  sheaths  of  muscles;  but,  in 
place  of  chromic  catgut  where  a  last- 
ing, yet  absorbable  material  is  desired, 
the  author  is  very  fond  of  kangaroo 
tendon.  It  is  remarkably  benign  in 
the  tissues,  which  receive  it  with 
such  a  degree  of  toleration  that  large 
strands  are  carried  readily,  and  the 
kangaroo  tendon  lasts  in  the  tissues 
for  a  longer  time  than  chromic  catgut, 
unless  the  latter  is  prepared  in  a  way 
which  makes  it  so  hard  as  to  be 
irritating. 

POSTOPERATIVE  TREAT- 
MENT.— The  patient  on  being  re- 
turned to  bed  should  have  wool  next 
the  skin  and  hot  bottles  at  the  ex- 
tremities, even  though  not  much 
shock  be  present,  for  shock  is  present 
to  some  degree  after  almost  any 
abdominal  operation,  due  to  stimula- 
tion of  the  afferent  nerves  of  the 
brain  and  cord  centers,  with  more  or 
less  lack  of  vasomotor  power.  There 
is  apt  to  be  more  or  less  perspiration 
from  leaking  sweat-glands  when  the 
patient  is  placed  in  bed,  and  any 
undue  exposure  at  this  time  may  lead 
to  a  chilling  which  would  be  inducive 


ABDOMEN,   SURGERY   OF    (MORRIS). 


to  postoperative  pneumonia.  For  the 
first  twenty-four  hours  approximately 
the  disturbance  of  the  intimate  gang- 
lia of  the  bowel  will  usually  result  in 
derangement  of  function  of  the  bowel 
so  that  any  food  material  is  apt  to 
undergo  fermentation  instead  of  diges- 
tion, and  the  toxemia  from  such  fer- 
mentation may  be  very  injurious,  and 
might  give  rise  to  serious  complica- 
tions. 

Thirst  is  inseparable  from  the  post- 
operative period,  and  hot  water  given 
in  teaspoonful  doses  frequently  will 
partially  allay  the  thirst,  and  supply 
all  the  real  needs  of  the  stomach 
for  some  hours  after  the  operation. 
Patients  are  very  urgent  at  times  in 
their  demands  for  cold  water  or  ice 
after  an  operation,  but  cold  water  has 
a  distinct  tendency  to  increase  vomit- 
ing, and  ice  in  the  mouth  produces 
the  same  reaction  that  cold  does  upon 
the  skin,  as  one  observes  after  making 
snowballs :  the  hands  become  red  and 
irritated,  and  in  the  same  way  the 
mucous  membrane  of  the  mouth  and 
pharynx  becomes  irritated,  if  the 
patient  is  allowed  ice  or  ice-water, 
excepting  in  the  most  minute  quanti- 
ties. 

It  has  been  the  practice  with  surgeons 
.  after  abdominal  operations  to  with- 
hold water  by  the  mouth  for  twenty- 
four  hours,  or  until  the  patient  is  free 
from  nausea  and  vomiting.  During 
this  time  the  thirst  is  distressing. 

Some  surgeons  have  for  several  years 
administered  water  by  the  rectum  in 
small  quantities  to  allay  thirst ;  but  the 
routine  method  of  injecting  a  large 
quantity  of  saline  solution  (0.6  per 
cent.)  for  the  prevention  of  thirst  after 
abdominal  operations  was  first  resorted 
to  in  the  Johns  Hopkins  Hospital.  The 
procedure  consists  in  the  injection  of 
a  quart  of  normal  saline  solution  into 
the  lower  bowel  immediately  at  the 
close   of   the   operation   and   while   the 


patient  is  still  under  the  influence  of 
the  anesthetic.  The  patient  is  elevated 
to  the  moderately  high  Trendelenburg 
posture,  a  stiff  rectal  tube  is  inserted 
well  up  into  the  sigmoid  flexure,  and 
the  fluid  slowly  poured  into  a  glass  fun- 
nel, which  is  held  3  or  4  feet  above  the 
level  of  the  patient's  buttocks. 

John   G.   Clarke   reviewed  the   charts 
of    100   abdominal    section   cases   which 
had  not  and    100  cases   which  had  re- 
ceived the  saline  enemata;  he  was  able 
to    report   the    most    gratifying    results 
not  only  in  the  alleviation  of  thirst,  but 
also  in  the  reduction  to  a  minimum  of 
vesical  irritability,  which  is  so  common 
in    operative     cases.      W.     M.     Taylor 
(Memphis   Med.   Monthly,   Feb.,   1897). 
Saline    rectal    infusion    is    a    most 
valuable  means  of  relieving  thirst  so 
frequently    complained    of    after    ab- 
dominal   operations.     A.    S.    Morrow 
(Diagnostic  and  Therapeutic  Technic, 
p.  509,  1911). 
Diet. — The  first  food  to  be  borne 
after  the  hot-water  period  is  passed 
is  liquid  diet  and  predigested  milk,  or 
fermented  milk  of  several  kinds,  and 
broths    are    usually    well   borne.      In 
two  or  three  days,  if  the  temperature 
and  other  vital  signs  are  fairly  normal, 
a    more    liberal    diet    will    allow    the 
patient     to     regain      strength     more 
rapidly.    Meteorism,  which  is  usually 
present  to  some  extent,  with  or  with- 
out colic,  because  of  the  disturbance 
of    the    sympathetic    ganglia    of    the 
abdomen,  may  be  relieved  ordinarily 
if    stimulating    enemata    are    given ; 
but  for  the  most  part  it  is  well  to 
leave  the  patients  pretty  much  alone, 
without  attempting  to  do  too  much 
for  them  during  the  first  twenty-four 
hours  after  an  abdominal  operation. 
Many    times    the    author    has    asked 
patients  what  they  most  desired  during 
the  first  day  after  an  abdominal  opera- 
tion,   and    the    common   answer    has 
been  that  their  greatest  desire  was  to 
be  left  alone. 


10 


ABDOMEN,    SURGERY   OF    (MORRIS). 


Opiates. — There  is  a  general  ten- 
dency to  give  opium  in  some  form 
after  abdominal  operations,  if  the 
patient  is  in  pain,  but  we  must 
remember  the  specific  action  of  opium 
in  lessening  the  resistance  to  the 
spread  of  infection  immediately  after 
an  operation,  and  not  apply  mistaken 
efforts  at  kindness  in  wishing  to  quiet 
the  patient's  pain.  There  are  some 
patients  of  nervous  temperament  who 
suffer  so  much  and  who  are  so  rest- 
less that  they  tire  themselves  out  with 
fretting,  if  we  do  not  give  opium  in 
some  form. 

Consequently  the  resource  is  one 
that  we  may  be  obliged  to  use,  but  it 
should  not  be  used  excepting  with 
full  knowledge  of  its  danger.  It  is 
the  author's  habit  to  tell  patients  in 
advance  of  operation  that  they  are 
going  to  suffer  a  great  deal  afterward 
from  colic,  nausea  and  pain,  but  that 
they  will  arrive  at  a  comfortable 
stage  soon  afterward.  The  effect  of 
this  statement  to  the  patient  has 
never,  so  far  as  the  author  knows, 
deterred  anyone  from  having  an  op- 
eration done,  as  there  is  the  natural 
feeling  of  pride  in  being  able  to  meet 
such  conditions,  and  the  patient,  ex- 
pecting a  good  deal  of  trouble  imme- 
diately after  operation,  and  prepared 
for  it,  is  frequently  enough  surprised 
to  find  it  so  much  less  in  degree  than 
had  been  anticipated. 

Insomnia  is  so  dependent  on  stom- 
ach and  bowel  disturbances  that  the 
two  belong  closely  in  association. 
Insomnia  which  is  dependent  upon 
the  disturbance  following  an  opera- 
tion is  not  so  distressing  if  the  patient 
has  a  good  nurse  who  suggests  quiet 
in  all  of  her  movements,  and  who 
does  not  allow  avoidable  disturbances 
to  keep  the  patient  awake.    Sleep  will 


be  established  frequently  in  a  natural 
way  b}^  the  third  night.  Part  of  this 
insomnia  at  night  is  due  to  the  fact 
that  patients  doze  off  at  various  times 
during  the  day,  and  really  get  during 
the  twenty-four  hours  about  all  of  the 
sleep  that  is  necessary.  A  number  of 
ordinary  hypnotics,  avoiding  the  opium 
preparations,  will  give  some  relief, 
and  this  is  a  matter  which  must  be 
left  to  the  judgment  in  individual 
cases  rather  than  stated  in  the  way 
of  a  general  rule. 

Should  the  patient  be  allowed  to 
leave  his  bed  early?  The  suitable 
cases  after  abdominal  section  are 
those  in  which  traumatism  within  the 
peritonevim  is  slight.  Great  care  is 
necessary  in  the  selection  of  these 
cases,  because  union  of  the  abdominal 
wound  may  not  be  strong-  enough  to 
withstand  the  intra-abdominal  pres- 
sure of  sneezing  or  coughing  even  so 
late  as  the  twelfth  day.  Vance  (New 
York  Med.  Jour.,  Feb.   16,  1907). 

The  writer  allowed  100  patients  to 
rise  in  the  course  of  the  first  week 
after  laparotomy,  13  on  the  first  day, 
16  on  the  second  da3%  21  on  the  third, 
30  on  the  fourth,  10  on  the  fifth,  8  on 
the  sixth,  and  2  on  the  seventh  day, 
and  has  been  much  pleased  with  the 
results.  Thrombosis  occurred  in  3 
cases,  but  soon  subsided;  the  condition 
was  evidently  responsible  for  it.  It  is 
advisable  to  be  cautious  in  allowing  pa- 
tients to  get  up  very  early  when  they 
had  unduly  high  temperature  or  dis- 
turbances in  circulation  in  the  legs  or 
pelvis,  but  under  other  conditions  it  is 
an  important  advance  in  the  treatment. 
F.  Cohn  (Zentralbl.  fiir  Gynak.,  Sept. 
19,   1908). 

No  matter  what  the  lesion  or  how 
weak  the  patients,  the  writer  has  them 
recover  from  ether  in  the  sitting  pos- 
ture by  means  of  a  bedrest.  He  keeps 
them  in  this  posture  for  about  twelve 
hours,  and  then  allows  them  to  lie  down 
and  turn  in  any  position  that  is  com- 
fortable. They  sit  up  again  with  a  bed- 
rest practically  all  the  next  twenty-four 


Abdomen,  surgery  of  (morris). 


11 


hours.  On  the  third  day,  if  strong,  but 
anyway  on  the  fourth  day,  he  has  them 
in  a  chair.  On  the  fourth  or  fifth  day 
they  walk  around.  From  that  time  on 
they  walk  or  sit  up  with  their  clothes 
on  during  the  day,  leaving  the  hospital 
usually  from  the  tenth  to  the  fourteenth 
dav.  Chandler  (Albany  Med.  Annals, 
Feb.,   1908). 

Report  based  on  results  in  164  cases 
of  laparotomy  which  were  allowed  to 
leave  the  bed  between  one  and  three 
days  after  laparotomy.  Of  these,  SO 
were  for  hernia ;  56  for  interval  appen- 
dicitis ;  20  for  acute  appendicitis ;  7  for 
cyst  of  the  ovaries;  4  for  uterine 
myoma ;  8  for  Alexander  Adams's  op- 
eration ;  3  for  cholecystectomy ;  3  for 
gastroenterostomy,  and  4  for  entero- 
anastomosis.  The  rest  were  instances 
of  exploratory  laparotomy.  Of  all 
these  cases,  1  only  suffered  from  throm- 
bosis, and  that  to  a  mild  extent.  The 
formation  of  a  firm  cicatrix  occurred 
promptly  in  all.  Perfect  narcosis  with- 
out vomiting  or  other  untoward  effects, 
rapid  operating  and  but  little  loss  of 
blood,  firm  and  close  fascial  suture,  and 
aseptic  healing  of  the  wound  are  essen- 
tial to  success.  Kummell  (Zentralbl. 
fiir  Chir.,  Bd.  xxxv,  S.  4,  1908). 

The  writer  does  not  believe  in  keep- 
ing patients  upon  whom  laparotomy  has 
been  performed  several  weeks  in  bed. 
If  there  are  no  indications  of  fever 
he  is  inclined  to  let  them  get  up  after  a 
few  days,  dependent  greatly  on  the  pa- 
tient's own  desire.  When  there  is 
fever,  however,  the  patients  are  kept  in 
bed,  as  early  rising  may  then  do  harm. 
The  objections  usually  urged,  dangers 
of  secondary  hemorrhage,  breaking 
open  of  the  wound,  and  embolism,  are 
theoretical  rather  than  practical.  Har- 
tog  (Berl.  klin.  Woch.,  March  IS, 
1909) . 

We  are  still  too  much  tied  down  in 
this  respect  by  the  traditions  of  the  old, 
bad  S3^steni  of  septic  surgery  with  its 
suppurating  wounds.  When  a  Avound 
is  full  of  pus  no  relaxation  can  be  al- 
lowed, but  aseptic  wounds  are  a  new 
development  and  must  be  judged  by 
totally    different    standards.     So    far   as 


these  are  concerned,  it  is  time  that  we 
discard  ancient  authority  and  think  out 
the  matter  for  ourselves.  In  the  first 
place,  a  clear  distinction  must  be  drawn 
between  allowing  a  patient  to  be  lifted 
quietly  out  of  bed  and  placed  in  a  com- 
fortable chair  with  abundance  of  cush- 
ions and  pillows  for  a  few  hours  each 
day,  for  the  sake  of  having  his  meals 
in  comfort  or  for  other  reasons,  and 
letting  him  get  up  and  get  about  by 
himself,  doing  whatever  he  thinks  fit. 
The  latter  is  opposed,  if  for  no  other 
reason  than  that  it  is  impossible  to 
guarantee  the  patient  against  accidents. 
Moullin    (Clin.  Jour.,  March  16,  1910). 

POSTOPERATIVE  COMPLICA- 
TIONS.— Shock  when  severe  in  de- 
gree requires  special  treatment  in 
addition  to  the  customary  methods 
for  retaining  the  body  heat  and  keep- 
ing hot  bottles  at  the  extremities. 
Elevation  of  the  foot  of  the  bed 
temporarily  allows  the  heart  to  work 
with  less  effort,  but  we  have  to  be 
guarded  about  suddenly  lowering  the 
foot  of  the  bed  at  any  time  while  the 
patient  is  still  in  a  condition  of  shock. 
The  patient  at  this  time  may  be  suffer- 
ing from  one  of  two  kinds  of  anemia : 
anemia  due  to  lack  of  vasomotor 
power  and  perhaps  also  anemia  due  to 
direct  loss  of  blood.-  For  the  anemia 
due  to  loss  of  vasomotor  power 
secondary  to  derangement  of  function 
caused  by  disturbance  of  the  sympa- 
thetic ganglia  of  the  abdomen  strych- 
nine is  indicated,  and  should  be  given 
hypodermically  in  doses  of  from  a 
thirtieth  to  a  twentieth  at  intervals  of 
about  four  hours. 

For  the  anemia  due  to  actual  loss 
of  blood  the  indications  are  for  sup- 
plying the  loss  of  blood  temporarily, 
and  this  is  done  either  by  direct  trans- 
fusion of  blood  or  more  commonly  by 
intravenous  infusion  of  normal  saline 
solution.     In  cases  in  which  we  have 


12 


ABDOMEN,   SURGERY   OF    (MORRIS). 


both  kinds  of  anemia  present  at  the 
same  time  the  use  of  the  strychnine 
rnay  be  quickly  transitory  and  injuri- 
ous, unless  we  have  first  by  transfu- 
sion or  infusion  given  the  heart  and 
blood  circulatory  system  the  mechan- 
ical advantage  of  possessing  a  full  com- 
plement of  fluid. 

Adrenalin  or  digitalis  are  powerful 
stimulants,  but  they  stimulate  the 
heart  out  of  proportion,  and  are  very 
transitory  in  effect,  and  unless  given 
with  great  caution  may  lead  to  over- 
stimulation, especially  if  given  in  con- 
junction with  strychnine.  Overstimu- 
lation will  be  followed  by  secondary 
shock  coming  on  a  few  hours  after 
apparent  recuperation  from  the  first 
evidences  of  shock.  Bandaging  the 
legs  firmly  in  order  to  driA^e  out  the 
blood  in  part  and  give  the  heart  less 
work  is,  like  elevation  of  the  foot  of 
the  bed,  a  resource  of  temporary 
value,  but  we  need  to  be  guarded 
about  removing  the  bandages  before 
recuperation  from  the  condition  of 
shock  is  well  established. 

The  best  method  of  administering 
the  adrenal  principle  is  by  continuous 
rectal  injection  in  saline  solution,  1 
dram  of  solution  of  adrenalin  to  a 
pint  of  the  saline  solution — that  is  to 
say,  1  in  160,000;  the  temperature  of 
the  liquid  should  be  between  108°  and 
112°  F.,  and  it  should  be  allowed  to 
flow  in  not  faster  than  at  the  rate  of 
1  pint  an  hour.  A.  J.  Walton  (Lan- 
cet, July  11,   1908). 

Adrenalin  will  raise  the  blood-pres- 
sure in  normal  animals  in  every  degree 
of  shock,  with  the  medulla  cocainized, 
or  in  the  decapitated  animal.  It  is 
rapidly  oxidized  by  the  solid  tissue  and 
by  the  blood.  Its  effect  is  fleeting;  it 
must,  therefore,  be  given  continuously. 
By  this  means  the  circulation  of  a  de- 
capitated animal  was  maintained  ten 
and  a  half  hours.  G.  W.  Crile  (Med. 
News,  Nov.  29,  1902). 


Hypodermic    injections    are    absorbed 
very  slowly  in  the  blood-stream  during 
severe     shock,     but    intravenous    injec- 
tions of  the   adrenal  principles,  adre- 
nin,  etc.,  or  of  pituitary  extracts,  raise 
the  blood-pressure  to  a  greater  extent 
than    in    the    normal    state,    a    single 
injection  of  an  extract  of  the  poste- 
rior lobe  of  the  pituitary  influencing 
arterial  tone  for  upward  of  an  hour, 
i.e.,  long  enough  to  produce  recovery 
in  some  cases.     Mummery  and  Symes 
(Brit.  Med.  Jour.,  vol.  ii,  p.  790,  1908). 
In    3    cases    of    postoperative    shock, 
the  writer  injected   1   c.c.   of   a  20  per 
cent,   solution   of  the   posterior  lobe  of 
the     pituitary     body     intramuscularly 
into  the  patient's  arm  before  the  pa- 
tient   had    fully    recovered    from    the 
anesthetic.      The    effect    was    almost 
immediate,    and    the    almost    imper- 
ceptible pulse  soon  became  large  and 
bounding.     This     effect     lasted    from 
twelve    to    sixteen    hours,    and   grad- 
ually  passed    off.      Not   only    did   the 
pulse  become  larger  in  expansion,  but 
it   was    also    slowed,    and   whereas    it 
had  been  irregular  it  became  regular. 
This  effect  seems  due  not  only  to  the 
action  of  the  drug  on  the  blood-ves- 
sels, but  also  on  the  heart.     The  in- 
jection was  given  in  conjunction  with 
normal  saline  by  rectum.    G.  G.  Wray 
(Brit.  Med.  Jour.,  Dec.  18,  1909). 
Meteorisrn  of  extreme  degree  also 
appears    to    depend    upon    two    chief 
factors :  partial  paralysis  of  the  mus- 
cularis  of  the  alimentary  tube  due  to 
disturbance   of  the   sympathetic   cen- 
ters, and  to  fermentation  of  contents 
of    the    alimentary    tract    caused    by 
saprophytes,  which   gain   ascendancy 
when  the  normal  control  occurring  in 
the. course  of  undisturbed  digestion  is 
taken  away.     The  meteorisrn  second- 
ary to   mechanical  obstruction   or  of 
spreading    peritonitis    includes    these 
same  prime  factors,  but  the  different 
forms  of  this  condition  require  treat- 
ment based  upon  causation  in  the  indi- 
A'idual  case.     The  meteorism  which  is 
due  to  simple  shock  calls  for  mechani- 


ABDOMEN,    SURGERY    OF    (MORRIS). 


13 


cal  treatment  chiefly,  although  the 
fermentation  of  intestinal  contents  is 
relieved  to  some  extent  by  the  use  of 
subgallate  of  bismuth  as  an  intestinal 
antiseptic,  and  by  the  use  of  the  lactic 
acid  ferment,  consisting  of  prepared 
cultures  of  the  Bacillus  Biilgaricns, 
which  now  may  be  obtained  in  tablet 
form,  or  which  may  be  used  indirectly 
in  milk  prepared  by  the  action  of  this 
bacillus. 

Mechanical  resources  consist,  in 
ordinary  cases,  of  introducing  a  rectal 
tube  to  allow  the  earh^  escape  of  gas, 
and  by  abdominal  massage  applied 
gently  but  persistently,  beginning  at 
the  right  side  over  the  cecum  and  car- 
r3'ing  the  massage  along  the  entire 
course  of  the  colon.  This  order  of 
massage  movements  seems  to  relieve 
distention  of  the  small  bowel  quite  as 
well  as  the  colon,  probably  because  of 
the  natural  tendency  toward  emptying 
of  the  small  bowel  into  the  colon.  In 
the  presence  of  severe  colic  in  meteor- 
ism,  massage  would  seem  to  be  contra- 
indicated,  but  it  is  not,  because  colic  is 
due  to  a  spasm  of  the  muscularis  of  the 
bowel,  in  its  effort  to  contract  to  the 
normal  caliber,  and  massage  move- 
ments seem  to  give  to  the  bowel  the 
same  sense  of  security  that  is  obtained 
by  a  splint  in  cases  of  fracture  with 
muscular  spasm  of  the  extremities. 
The  author  is  impressed  by  the  fact 
that  treatment  of  meteorism  of  the 
bowel  in  this  way  by  massage  and  by 
the  rectal  tube  is  not  commonly  appre- 
ciated as  it  should  be,  and  he  has  very 
many  times  afforded  decided  and  last- 
ing relief  by  these  resources. 

A  hj'podermic  injection  of  y^o  grain 
of  salicylate  of  eserine  gives  excellent 
results  in  cases  of  tympanites  after 
colotomy.  Within  fifteen  minutes  of 
its  injection  the  patient  begins  to  pass 
flatus.    An  enema  of  sulphate  of  mag- 


nesium should  then  be  given.  The  re- 
sult is  often  marvelous.  If  necessary, 
the  injection  may  be  repeated  in  six 
hours  without  danger.  F.  E.  Taylor 
(Treatment,  Feb.,  1906). 

Acute    dilatation    of    the    stomach 

belongs  to  the  same  category,  is  prob- 
ably dependent  upon  the  same  causes 
as  meteorism  of  the  bowel,  and  has 
practically  the  same  order  of  compli- 
cations. In  many  cases  there  seems 
to  be  selective  impression  made  upon 
the  innervation  of  the  stomach  by 
shock,  perhaps  because  of  its  proxim- 
ity to  the  solar  plexus,  and  dilatation 
of  the  stomach  occurs  out  of  propor- 
tion to  dilatation  of  the  bowel.  When 
we  recognize  acute  dilatation  of  the 
stomach  by  the  persistent  vomiting, 
distress,  and  visible  distention  of  the 
upper  left  quadrant  of  the  abdomen 
in  excess  of  distention  of  other  parts 
of  the  abdomen,  we  have  the  charac- 
teristic features  of  this  form  of 
meteorism.  In  this  condition  the 
mechanical  features  of  treatment  are 
all  important,  and  are  obtained  by 
placing  the  patient  prone  upon  the 
abdomen,  with  the  result  of  causing 
constant  compression  of  the  distended 
stomach.  With  the  patient  in  this 
position,  the  stomach  tube  introduced 
at  frequent  intervals,  washing  of  the 
stomach  with  warm  saline  solution 
results  in  causing  the  escape  of  very 
large  quantities  of  gas.  Patients  suf- 
fering from  this  condition  are  not 
so  sensitive  to  the  introduction  of  the 
stomach  tube  as  many  others,  and 
the  immediate  relief  which  is  given 
temporarily  often  makes  them  eager 
for  the  next  introduction  of  the  tube. 
The  important  matter  is  to  applv  the 
stomach  tube  often  enough,  and  this 
is  a  point  commonly  neglected.  AVe 
must  keep  the  stomach  empty  of  gas 
and  fermenting  contents. 


14 


ABDOMEN,    SURGERY   OF    (MORRIS). 


In  cases  in  which  the  patient  hap- 
pens to  rebel  against  introduction  of 
the  stomach  tube  because  of  highly 
sensitive  fauces  we  may  spray  the 
fauces  in  advance  with  cocaine  solu- 
tion, and,  if  the  tube  is  lubricated  with 
a  nice  quality  of  sweet  oil  to  which 
is  added  a  few  drops  of  wintergreen, 
the  patient,  relishing  this,  will  chew 
the  tube  for  a  few  moments,  and  then 
begin  swallowing  it.  Further  advance 
of  the  tube  is  made  by  the  surgeon. 

Meteorism  due  to  mechanical  ob- 
struction of  the  bowel  is  also  met 
with.  At  the  present  time  we  see  very 
much  less  of  dynamic  and  adynamic 
ileus  than  we  did  a  few  years  ago, 
when  it  was  common  practice  to  use 
gauze  packing  in  abdominal  surgery. 
This  gauze  packing  lowered  the 
patient's  general  resistance,  as  a 
foreign  body  in  the  peritoneal  cavity. 
It  caused  excessive  exudation  of 
plastic  lymph  from  peritoneal  sur- 
faces, and  adhesion  angulation  was  a 
frequent  feature  in  consequence,  or  if 
not  angulation,  the  arrest  of  peristalsis 
from  the  involvement  of  the  long 
segments  of  the  bowel  among  adhe- 
sions. 

That  form  of  ileus  in  which  per- 
istalsis progresses  violently  up  to  the 
point  of  arrest  with  a  rapid  produc- 
tion of  graA^e  symptoms  can  often- 
times be  relieved  by  posture.  If  the 
patient's  hips  and  legs  are  elevated 
upon  the  back  of  a  chair  which  has 
been  placed  upside  down  in  bed,  and 
gentle  massage  applied,  gravitation 
will  sometimes  stop  the  angulation  or 
kinking  of  bowel  in  a  few  minutes, 
and  it  is  gratifying  to  see  the  whole 
picture  of  a  desperate  case  change  so 
rapidly  as  it  sometimes  will  when 
this  posture  resource  is  being  applied, 
together  with  gentle  massage.     Re- 


opening of  the  abdomen  and  a  search 
for  the  point  of  mechanical  obstruc- 
tion are  such  very  fatal  procedures 
that  they  must  not  be  employed  with 
much  hope  of  obtaining  relief,  but 
some  authors  hope,  which  the  author 
does  not  share  freely,  to  secure  an 
occasional  good  result  by  opening  the 
distended  bowel  by  incising  it  after 
reopening  the  abdominal  cavity  to 
allow  the  escape  of  gas,  or  by  inject- 
ing sulphate  of  magnesia  solution 
through  trocar  punctures  in  the 
bowel.  Clinically  I  think  that  we 
may  usually  observe  that  when  the 
bowel  is  opened  at  any  point  for  the 
escape  of  gas  it  allows  the  escape  of 
gas  only  in  the  immediate  vicinit}^ 
the  paralysis  of  the  bowel  preventing 
the  contraction  necessary  for  empty- 
ing the  lumen  at  more  distant  points. 
Rapid  opening  of  the  distended  bowel 
at  a  point  above  the  obstruction,  inser- 
tion of  a  drain  to  carry  off  the  poison- 
ous contents,  and  subsequent  operation 
for  the  relief  of  the  obstruction,  after 
the  patient  has  made  some  gain,  is  oc- 
casionally successful. 

Our  resources  must  be  applied 
promptly  in  cases  of  ileus  with 
meteorism,  because  toxins  generated 
in  any  part  of  the  bowel  which  is  not 
emptying  itself  rapidly  lead  to  a 
dangerous  toxemia,  and  the  colon 
bacillus  particularly  increasing  in 
virulent  culture  in  an  obstructed  or 
paralyzed  part  of  the  bowel  may  not 
only  cause  general  toxemia,  but  may 
be  carried  to  the  kidneys  and  liver, 
and  there  give  origin  to  a  train  of 
serious  complications  discussed  under 
the  next  heading. 

Colon  Bacillus  Nephritis. — If  this 
continues  after  relief  from  the  ileus 
has  •  been  obtained,  it  will  require 
special    treatment    internally.      Five 


ABDOMEN,    SURGERY   OF    (MORRIS). 


15 


grains  of  benzoate  of  soda  coml)incd 
with  five  grains  of  hexamethylenamine 
administered  at  rather  frc(|uent  inter- 
vals, accordino-  to  the  judgment  of  the 
physician,  will  exert  a  specific  influeiice 
upon  the  complication  of  colon  bacil- 
lus nephritis  which  so  commonly 
follows  various  causes  of  loss  of 
confrol  over  this  bacterium.  When  the 
benzoate  of  soda  and  hexamethylena- 
min  internally  do  not  control  colon 
bacillus  nephritis  in  a  satisfactory  way, 
the  pelvis  of  the  kidneys  may  be 
flushed  through  a  ureteral  catheter. 

In  many  cases  one  may  state  inci- 
dentally that  colon  bacillus  nephritis  is 
often  enough  present  in  advance  of 
operation  in  many  abdominal  condi- 
tions, passing  for  ordinary  nephritis, 
unless  one  devises  means  for  de- 
termining if  the  colon  bacillus  is 
present,  and  the  author  has  known  of 
instances  in  which  excellent  consult- 
ants wished  to  postpone  operation 
because  of  the  presence  of  albumin- 
uria, when,  as  a  matter  of  fact,  this 
albuminuria  was  due  to  the  presence 
of  the  colon  bacillus,  and  to  be  cured 
only  after  removal  of  the  focus  of 
original  infection  by  the  abdominal 
operation.  The  colon  bacillus  nephri- 
tis which  occurs  with  appendicitis 
may  often  clear  up  rapidly  after  the 
operation  without  any  special  treat- 
ment directed  to  the  nephritis,  and 
the  same  result  may  be  anticipated  in 
a  certain  proportion  of  the  cases  of 
colon  bacillus  nephritis  occurring 
with  ileus. 

Meteorism  due  to  extension  of 
peritonitis  after  operation  is  some- 
times treated  by  the  old  Clark  opium 
method,  which  consists  in  placing  the 
patient  profoundly  under  the  influ- 
ence of  morphine.  It  acts  by  limiting 
the  spread  of  peritonitis  due  to  peris- 


taltic movements  of  the  l)o\vel,  and 
tlie  loss  of  resistance  on  the  part  of 
the  patient  from  the  shock  which 
goes  with  peritoneal  ])ain.  On  the 
other  hand,  we  have  the  objection  that 
bacteria  increase  more  rapidly  in  a 
patient  under  the  influence  of  opium. 
In  addition  to  the  beneficial  influence 
of  opium  in  selected  cases,  the  ice-coil 
placed  on  the  abdomen  has  the  tend- 
ency to  lessen  the  spread  of  peritonitis 
besides  limiting  the  pain. 

The  author  has  preferred  the  prin- 
ciple of  turning  the  blood-current 
toward  emunctories  of  the  bowel,  and 
securing  elimination  of  toxins  along 
with  a  free  watery  discharge  from  the 
mucosa  of  the  bowel.  This  is  accom- 
plished fairly  well  by  the  high  rectal 
injection  of  an  ounce  of  alum  in  a 
quart  of  water.  The  alum  in  the  bowel 
produces  the  same  effect  that  it  does 
in  the  mouth,  causes  rapid  watery 
secretion  from  neighboring  glands, 
and  incidentally  stimulates  contrac- 
tion of  the  paralyzed  bowel,  with 
emptying  of  its  contents.  We  might 
anticipate  that  alum  would  have  in 
the  bowel  an  astringent  effect,  with 
the  tendency  to  cause  constipation, 
but  it  has  precisely  the  reverse  action, 
and  the  great  amount  of  watery 
exudate  which  is  drawn  out  in  the 
presence  of  alum  seems  to  overcome 
any  irritating  effect  which  it  might 
have. 

Sulphate  of  magnesia  by  high  injec- 
tion has  an  effect  like  alum,  of  causing 
watery  evacuation  which  presumably 
carries  off  toxins,  and  the  influence  of 
sulphate  of  magnesia  is  probably  due 
to  its  hygroscopic  nature,  drawing 
fluids  from  the  peritoneal  cavity 
toward  the  bowel  lumen  by  osmosis. 
The  sulphate  of  magnesia  injection, 
either  alone  or  combined  with  glyc- 


16 


ABDOMEN,    SURGERY   OF    (MORRIS). 


erin,  which  is  also  hygroscopic,  is 
perhaps  the  favored  method  of  obtain- 
ing movement  when  there  is  any 
decree  of  paralysis  of  the  bowel,  but 
the  alum  injection  is  much  more 
effective,  and  willact  in  cases  where 
paralysis  is  established  to  such  a 
degree  that  sulphate  of  magnesia 
would  exert  no  apparent  influence. 
In  addition  to  these  rectal  injections, 
a  very  gentle  massage  is  effective  in 
some  cases  in  overcoming  the  par- 
alysis of  the  bowel,  although  it  seem- 
ingly would  be  counterindicated.  In 
cases  where  septic  peritonitis  is 
present  at  the  time  of  operation,  and 
there  is  danger  of  such  peritonitis 
remaining  as  a  postoperative  compli- 
cation, the  Murphy  proctoclysis  is 
invaluable.  This  consists  of  the  very 
slow  instillation  of  warm  saline  solu- 
tion into  the  rectum  continuously  for 
a  long  period  of  time,  and  many  forms 
of  special  apparatus  for  the  purpose 
have  been  devised.  The  apparatus  of 
Dr.  Robert  C.  Kemp  maintains  an  even 
temperature  of  the  saline  solution  by 
the  use  of  the  vacuum  principle  in  the 
container  of  the  fluid,  similar  to  that 
obtained  by  the  thermos  bottle.  The 
methods  here  described  for  treating 
cases  with  spreading  peritonitis  assume 
that  we  have  made  provision  for  suffi- 
cient drainage  and  have  applied  other 
resources  in  an  operative  way. 

Poisoning  by  bichloride  of  mercury 
and  by  iodoform  have  in  the  past 
been  com.mon  postoperative  compli- 
cations, although  at  the  present  time 
they  do  not  occur  so  frequently,  but 
still  require  attention.  Poisoning  by 
bichloride  of  mercury  through  absorp- 
tion from  large  wound  surfaces  gives 
rise  to  the  characteristic  irritation  of 
the  mucosa  of  the  alimentary  tract, 
but    seldom    appears    in    abdominal 


work,  because  there  is  almost  no 
situation  in  which  an  expert  operator 
would  think  of  using  bichloride  of 
mercury.  Iodoform,  however,  is  very 
frequently  used  in  abdominal  sur- 
gery, but  chiefly  with  iodoform  gauze, 
and  this  gives  rise  to  iodoform  poison- 
ing so  frequently  that  the  author  on 
one  occasion,  when  being  asked  to 
look  for  it  in  a  hospital  ward,  found 
several  cases  unsuspected  in  one 
ward.  Iodoform  is  taken  up  very 
rapidly  by  the  peritoneum,  and  its 
symptoms  are  commonly  mistaken  for 
the  symptoms  of  septicemia,  with 
rapid  pulse,  wet  skin,  and  peculiar 
mental  wandering. 

Where  we  have  occasion  to  sus- 
pect that  iodoform  poisoning  is  a 
postoperative  complication  in  abdom- 
inal work,  we  may  determine  the 
point  by  adding  a  pinch  of  calomel  to 
some  of  the  patient's  urine  in  a 
saucer,  and  stirring  with  a  wooden 
spatula.  If  free  iodine  is  present  in 
the  urine  it  makes  the  customary  re- 
action to  iodide  of  mercury,  distin- 
guished at  once  by  the  cloud  of  color. 
Removal  of  iodoform  gauze  from  the 
wound  in  such  a  case,  and  taking  up 
iodoform  which  is  adherent  to  the  tis- 
sues by  pouring  sterilized  oil  into  the 
cavity  from  which  the  gauze  was  re- 
moved, and  leaving  the  oil  there  for 
some  minutes  before  abstracting  it 
with  absorbent  apparatus,  will  com- 
monly allow  the  patient  to  recover 
from  a  severe  case  of  iodoform 
poisoning. 

Patients  vary  greatly  in  their  sus- 
ceptibility to  iodoform,  and  the  author 
observed  one  death  from  iodoform 
poisoning  with  characteristic  signs  in 
a  young  girl,  sixteen  years  of  age, 
in  a  case  in  which  he  arrived  too 
late  in  consultation.     And  the  young 


ABDOMEN,    SURGERY    OF    (MORRIS). 


17 


girl  had  been  poisoned  by  a  roll 
of  iodoform  gauze,  not  much  larger 
than  two  fingers  in  size,  after  an 
appendix  operation.  The  surgeon  in 
charge  had  been  absolutely  at  a  loss 
to  account  for  the  symptoms.  While 
there  are  positions  in  which  iodoform 
gauze  is  of  considerable  value  in 
small  quantities  in  abdominal  work, 
we  must  always  bear  in  mind  the 
danger  of  the  postoperative  compli- 
cation of  iodoform  poisoning. 

In  an  attempt  to  discover  the  cause  of 
the  skin  eruptions  seen  so  often  after 
abdominal  operations,  the  author  found 
that  these  occurred  most  often  in  pa- 
tients who  were  given  an  enema  of 
soapsuds  made  from  common  3^ellow 
soap,  but  if  Castile  soap  were  substi- 
tuted no  eruption  followed!  This  was 
corroborated  by  the  fact  that  in  ex- 
changing the  yellow  for  the  Castile  soap 
in  other  patients  who  had  these  erup- 
tions it  was  found  that  the  j^ellow  soap 
produced  rashes,  whereas  the  Castile 
soap  did  not.  It  was  then  found  that 
the  cheap  and  common  yellow  soap  con- 
tained a  considerable  quantity  of  resin, 
and  to  this  the  writer  believes  the  cause 
of  many  of  the  rashes  seen  after  ab- 
dominal section  must  be  attributed. 
F.  J.  Shepherd  (Jour,  of  Cutaneous 
Dis.,    July,    1909). 

Uncontrollable  _  vomiting  imme- 
diately following  operation  is  prob- 
ably due  to  excessive  stimulation  of 
the  nerves  of  the  stomach  through 
shock,  or  from  the  irritation  of  ether 
w^hich  is  being  excreted  by  the  glands 
of  the  stomach,  and  it  seems  to  be 
due  also  at  times  to  reversed  peris- 
talsis of  the  upper  part  of  the  bowel, 
throwing  contents  of  the  duodenum 
into  the  stomach,  and  the  continuance 
of  the  wave  of  reversed  peristalsis  to 
the  point  of  including  the  entire  stom- 
ach. This  complication  sometimes  be- 
comes so  dangerous  that  we  must  stop 
it  by  the  chief  means  at  our  control, 


giving  the  patient  the  harmful  mor- 
phine. 

Preperitoneal  hernia  is  sometimes 
the  cause  for  ileus  with  its  vomiting 
and  other  train  of  symptoms,  but  it 
is  not  likely  to  occur  in  cases  in  which 
the  operator  is  aware  of  the  danger  of 
this  complication,  and  has  guarded 
against  it.  Properitoneal  hernia  oc- 
curs in  cases  in  which  there  has  been 
defective  suturing  of  the  peritoneal 
layer  of  the  abdominal  wall  after 
operation,  and  a  small  knuckle  of 
bowel  is  forced  by  vomiting  or  cough 
into  the  space  between  the  peritoneum 
and  muscular  abdominal  wall. 

Hernia  into  a  rent  in  the  omentum 
may  occur  as  a  postoperative  compli- 
cation, and,  if,  in  the  course  of  separat- 
ing adhesions,  the  operator  has  left  any 
small  openings  in  the  omentum,  these 
should  be  extended  clear  to  the 
margin  of  the  omentum,  or  closed  by 
suture.  In  any  event,  possibility  of 
hernia  complication  should  be  foreseen 
in  all  work  which  deals  with  the  omen- 
tum, if  rents  are  left  unclosed. 

Perforation  of  the  bowel  some- 
times occurs  as  a  postoperative  com- 
plication at  the  site  where  a  rigid 
drainage  tube  or  bulky  drainage  ap- 
paratus has  caused  an  undue  amount 
of  pressure,  and  perforative  ulcer  may 
occur  a  few  da3^s  after  the  operation 
at  the  site  of  a  gastroenterostomy,  if 
the  bowel  has  been  fastened  so  far 
away  from  the  pylorus  that  acid  con- 
tents of  the  stomach  escape  directly 
into  the  bowel  at  the  point  of  junc- 
ture. 

Postoperative  phlebitis  occurs  often 
enough  to  require  attention.  It  may 
appear  two  weeks  after  an  aseptic 
operation,  and  its  origin  is  not  well 
understood.  As  a  postoperative  com- 
plication in  appendicitis,  it  sometimes 


1—2 


18 


ABDOMEN,    SURGERY    OF    (MORRIS). 


appears  as  an  inflammation  of  the  left 
iliac  vein  or  left  saphenous  vein,  and 
occurs  in  fact  at  a  distance  quite  as 
often  as  at  the  site  of  operation. 
While  causing-  a  high  degree  of  dis- 
comfort and  prolonging  the  period  of 
illness,  it  is  not  often  an  absolutely 
dangerous  complication.  If  abscesses 
are  formed,  they  are  apt  to  remain 
localized  rather  than  to  give  rise  to 
septic  embolism. 

Pylephlebitis  does  not  often  occur 
as  a  postoperative  complication,  ex- 
cepting, in  cases  in  which  we  have 
evidences  of  its  presence  in  advance 
of  operation,  but  abscess  of  the  liver 
may  appear  so  late  after  an  abdominal 
operation  that  the  relationship  be- 
tween the  primary  focus  of  infection 
in  the  peritonal  cavity  and  the  liver 
abscess  may  be  lost  sight  of.  A 
patient  may  even  leave  the  hospital, 
and  his  home,  and  travel  to  a  dis- 
tance for  recuperation,  with  beginning 
abscess  of  the  liver,  the  treatment 
for  which  will  receive  consideration 
under  the  heading  of  that  subject. 

Secondary  abscess  may  appear  at 
the  site  of  an  infection  which  has 
been  cared  for  at  the  time  of  opera- 
tion, but  such  secondary  abscess  is 
prone  to  liquefy  newly  coagulated 
lymph  toward  the  external  abdominal 
incision,  and  to  follow  this  line  of 
least  resistance,  rather  than  to  extend 
in  other  directions. 

Mesenteric  thrombosis  not  mark- 
edly present  at  the  time  of  an  opera- 
tion may  increase  to  become  a  post- 
operative menace,  due  probably  to 
injury  of  the  veins  in  the  course  of 
an  operation,  but  the  complication  is 
rare. 

Bladder  complications  do  not  call 
for  special  consideration  in  this  arti- 
cle.    The  bladder  sometimes  refuses 


to  contract  in  a  normal  way  after 
various  abdominal  operations.  This 
is  sometimes  due  to  nothing  more 
serious  than  the  unaccustomed  re- 
cumbent position  of  the  patient,  or 
to  physic  influence,  although  shock 
sometimes  leads  to  disturbance  of  the 
innervation  of  the  bladder,  and  at  the 
same  time  we  are  apt  to  have  hypose- 
cretion  of  urine  due  to  a  similar  influ- 
ence upon  the  kidneys.  It  is  best  to 
avoid  using  a  catheter  if  possible  for 
emptying  the  bladder,  and  it  is  seldom 
necessary,  excepting  when  we  have  di- 
rect evidence  of  an  overfull  bladder. 
Otherwise  it  is  best  to  resort  to  such 
resources  as  massage  of  the  bladder 
above  the  pubes,  and  the  sound  of 
trickling  water  upon  a  warm  bed- 
pan placed  beneath  the  patient.  If  we 
begin  too  early  to  use  the  catheter, 
there  is  a  tendency  for  the  bladder  to 
depend  upon  that  resource  for  some 
days,  and  sometimes  for  as  long  as  the 
patient  remains  in  bed,  if  we  begin  with 
the  mistaken  idea  that  prompt  use  of 
the  catheter  will  simplify  matters. 

Postoperative  psychoses  occasion- 
ally occur  after  abdonainal  operations, 
and  the  operation  is  commonly  held 
by  relatives  of  the  patient  to  be  the 
primary  cause.  Such  disturbances 
usually  mean  the  precipitation  of 
impending  psychoses  which  were  de- 
veloping in  advance  of  the  operation, 
but  kept  in  check  by  the  will  of  the 
patient  until  the  shock  and  surround- 
ings of  the  operation  relaxed  that 
control.  Such  psychoses  may  be  due 
to  central  causes,  but  are  also  some- 
times toxic  in  origin,  as  the  abdom- 
inal surgeon  sees  them,  and  such 
psychoses  precipitated  by  operation 
may  be  really  on  the  road  to  elimina- 
tion, due  to  removal  of  the  origin  of 
the  toxic  impression, 


ABDOMEN,    SURGERY   OF    (MORRIS). 


19 


Peritoneal  adhesions  causing-  trou- 
ble subsequent  to  operation  receive 
consideration  along-  with  that  general 
subject  elsewhere  in  the  article. 

Postoperative  pneumonia  occurs, 
according  "to  various  authors  who 
have  tabulated  many  thousands  of 
cases,  in  from  2  to  5  per  cent,  of  all 
abdominal  operations,  although  in 
practice  one  may  have  series  of  one 
or  two  hundred  operations  without  a 
single  case  of  pneumonia,  and  it  is 
very  much  less  frequent  today  as  the 
result  of  our  refinement  in  technique 
than  it  was  ten  years  ago.  True 
croupous  or  lobar  pneumonia,  lobular 
pneumonia  and  hypostatic  pneumonia 
may  all  stand  in  direct  relationship 
to  causes  which  are  more  or  less 
under  control  by  the  surgeon.  The 
development  of  true  lobar  pneumonia, 
developing  immediately  after  an 
operation,  seems  to  the  author  to  be 
more  than  a  coincidence.  The  dis- 
turbance incident  to  any  abdominal 
operation  may  lower  the  vitality  of 
the  patient  in  such  a  way  that  the 
omnipresent  pneumococcus  ma}^  sud- 
denly spring  into  activity,  particu- 
larly if  ether  has  been  the  anesthetic. 
We  have  recent  knowledge  that  in- 
fections of  various  sorts  may  begin 
quickly  in  animals  under  the  influence 
of  that  anesthetic.  The  shorter  the 
period  of  anesthesia,  and  of  operative 
procedure  which  lessens  general  re- 
sistance, the  less  we  shall  probably 
have  of  true  lobar  pneumonia,  which 
has  generally  been  held  to  be  merely 
coincidental. 

Hypostatic  pneumonia  after  abdom- 
inal operations  may  appear  for  the 
same  reasons  that  it  appears  else- 
where, but  neither  hypostatic  nor 
true  lobar  pneumonia  are  so  distinctly 
traced   as    postoperative    complications 


as  is  lobular  pneumonia,  and  this 
lobular  pneumonia  is  the  particular 
one  with  which  we  usually  have  to 
deal.  According  to  statistics,  lobular 
pneumonia  occurs  more  often  after 
abdominal  operations  on  the  aged, 
and  more  often  in  men  than  in 
women,  but  the  latter  feature  of  the 
statistics  does  not  have  special  refer- 
ence to  abdominal  operations.  While 
general  anesthetics  are  all  more  or 
less  irritating  to  the  bronchial 
mucosa,  and  postoperative  vomiting 
is  a  factor  allowing  aspiration  of 
mucus  or  substances  from  the  stom- 
ach, there  are  other  features  leading 
to  a  special  preponderance  of  lobular 
pneumonia  after  laparotom}-.  The 
pain  following  abdominal  operations 
interferes  with  full  range  of  the 
muscles  of  respiration  and  favors  pul- 
monary stasis,  but  direct  infection  of 
the  lungs  'by  bacteria  may  occur  in 
three  ways :  by  way  of  the  mucous 
membrane,  the  blood-  and  lymph- 
vessels.  After  abdominal  operations, 
with  a  tendency  to  pulmonary  stasis 
because  of  limited  respiration  on 
account  of  abdominal  pain,  and  reten- 
tion of  matters  which  would  be  ex- 
pectorated if  coughing  w^ere  not  so 
painful,  bacteria  arriving  at  the  lungs 
from  the  abdominal  region  by  w^ay  of 
the  blood-  and  lymph-  vessels  meet 
with  resistance  which  is  less  than 
normal.  The  author  believes  that 
long  exposure  of  the  peritoneum  in 
the  course  of  an  ordinary  operation 
may  lead  to  the  carrying  of  large 
numbers  of  air  bacteria  indirectly  to 
the  lung's  without  complete  destruc- 
tion en  route  by  phagocytes,  and  it  is 
his  impression  that  these  cases  are 
not  infrequent.  Embolic  pneumonia 
and  its  common  sequence  of  lung 
abscess     by     infection    through     the 


20 


ABDOMEN,    SURGERY    OF    (MORRIS). 


blood-stream  no  doubt  occurs  from 
the  handling  of  thrombosed  vessels, 
and,  while  we  recognize  certain  cases 
of  pneumonia  directly  due  to  the 
presence  of  the  larger  emboli,  it  is 
probable  that  we  have  many  other 
cases  in  which  minute  emboli  give 
rise  to  complications  which  appear  a 
few  days   after  operation. 

Pleurisy  frequently  follows  opera- 
tions upon  the  liver  and  gall-bladder, 
if  these  operations  are  for  cases  with 
infection.  Here  it  is  probable  that 
infection  is  transmitted  by  way  of  the 
lymphatics  through  the  diaphragm 
to  the  pleura,  and  the  neighboring 
lung  becomes  next  infected,  giving 
us  sometimes  the  dangerous  pleural 
pneumonia.  The  postoperative  com- 
plication of  pleurisy  or  of  pleural 
pneumonia  cannot  well  be  guarded 
against,  but  we  may  anticipate  the 
danger  of  postoperative  lobular  pneu- 
monia, and  lessen  this  complication 
very  distinctly  in  several  ways :  by 
avoiding  as  far  as  possible  unneces- 
sarily prolonged  operations  with  the 
accompanying  long  period  of  anes- 
thesia; by  maintaining  the  body 
warmth  of  the  patient,  and  by  allow- 
ing the  patient  postures  which  favor 
expectoration.  It  is  probable  that 
the  Fowler  position  after  operation, 
while  not  particularly  favoring  ex- 
pectoration, may  lessen  the  danger 
from  embolic  pneumonia  to  some 
extent. 

Fistulas  from  the  alimentary  tract 
and  bile-tract  are  sometimes  annoy- 
ing as  postoperative  complications, 
but  when  not  formed  purposely  for 
useful  purposes  they  have  a  remark- 
able tendency  to  close  spontaneously 
if  left  alone.  Very  much  harm  is 
done  almost  as  a  matter  of  routine  at 
the    present    moment    by    surgeons, 


house  staff  assistants  and  nurses  in 
their  eft'orts  at  keeping  such  fistulse 
carefully  cleansed.  Antiseptics  intro- 
duced into  such  fistulae  cause  disturb- 
ance of  the  delicate  new  cells  which 
are  being  thrown  out  for  purposes  of 
repair,  and  even  so  harmless  a  solu- 
tion as  saline  solution  is  commonly 
injurious  in  fistulse.  Employment  of 
hydrogen  dioxide,  which  cleanses 
fistulse  in  a  most  attractive  way,  is 
one  of  the  most  injurious  of  resources, 
because  it  destroys  new  cells  quite  as 
readily  as  it  destroys  pus.  In  cases 
in  which  we  have  reason  to  suspect 
that  a  fistula  is  kept  open  by  some- 
thing at  the  bottom  of  the  fistula,  as 
a  knot  of  unabsorbed  ligature,  a  con- 
cretion, a  bit  of  fecal  matter,  or  other 
foreign  body,  we  shall  usually  need 
to  operate,  for  efforts  at  closing  such 
fistulse  are  usually  very  futile  until 
the  foreign  body  is  out. 

Excepting  in  cases  in  which  we 
believe  that  a  foreign  body  lies  at  the 
bottom  of  the  fistula,  our  treatment 
had  best  be  a  treatment  of  neglect, 
doing  nothing  whatsoever  in  the  way 
of  cleansing  the  fistula,  and  simply 
using  an  external  dressing  for  the 
purpose  of  cleanliness.  Under  this 
treatment  new  repair  cells  quickly 
form  connective  tissue,  and  such  con- 
nective tissue,  according  to  its  well- 
known  habit,  contracts  regularly  and 
closes  fistula.  There  are  a  few  cases 
in  which  epithelium  will  move  down- 
ward from  the  skin  and  upward  from 
the  bowel,  forming  an  epithelial 
covering  for  the  walls  of  a  short  fistula, 
and  when  such  short  fistulse  are  seen 
to  have  an  epithelial  lining  this  may 
be  destroyed  by  leaving  95  per  cent. 
carbolic  acid  along  the  line  of  the 
fistula  for  half  a  minute,  and  then 
neutralizing   it   with   alcohol.     After 


ABDOMEN,   SURGERY   OF    (MORRIS). 


21 


the  destruction  of  epithelium  in  this 
way  by  carbohc  acid,  new  cells  arc 
formed,  but  we  must  be  sure  that 
epithelial  cells  do  not  again  cover  the 
surface,  and  to  guard  against  this  the 
highly  astringent  subsulphate  of  iron 
is  effective  as  an  astringent  which 
will  not  allow  new  epithelial  cells  to 
grow,  but  which  does  not  prevent 
the  development  of  connective-tissue 
cells,  although  connective  tissue 
formation  in  such  cases  is  tedious. 

One  of  the  most  persistent  fistulas 
in  the  author's  practice  followed  an 
operation  for  perforating  ulcer  of  the 
duodenum,  in  a  patient  whose  large 
size  and  desperate  condition  did  not 
allow  detailed  work  at  the  ulcer  site 
at  the  time  of  operation.  This  fistula 
discharged  pancreatic  secretion,  bile 
and  chyme  for  some  months,  but 
finally  closed  spontaneously.  As  a 
rule,  it  is  best  to  allow  the  patient 
with  a  postoperative  fistula  to  get  out 
of  bed  as  soon  as  the  wound  is 
secured  in  the  ordinary  way,  and  the 
patient  then  goes  about  his  ordinary 
occupation  and  engages  in  all  sorts 
of  activities,  wath  no  attention  to  the 
fistula  beyond  the  ^vearing  of  a  small 
external  pad  of  gauze  for  the  purpose 
of  neatness. 

Objects  left  behind  after  abdominal 
operations  have  led  to  complications 
in  imposing  array  among  statistics, 
and  the  gauze  pad  has  been  the  chief 
offender. 

Reports  of  100  cases  of  foreign  bodies 
left  in  the  abdomen  after  celiotomy. 
Fifty-eight  patients  recovered ;  42  died. 
Twenty-nine  times  a  sponge  was  lost, 
twenty-eight  times  a  tampon  or  gauze 
compress,  four  times  a  drainage-tube, 
and  nineteen  times  artery  forceps.  In 
a  number  of  instances  two  foreign 
bodies  were  left  in.  The  sponges  were 
generally  recovered  by  second  section. 
The    majority    of    tampons    and    com- 


presses were  discharged  spontaneously 
through  the  rectum.  Neugebaucr  (Zen- 
tralbl.   fiir  Chir.,  Nu.  3,   1900). 

The  writer  has  collected  ISS  cases  in 
which  foreign  bodies  were  left  in  the 
abdominal  cavity,  sugg-^sting  how  fre- 
quent this  serious  accident  is.  The 
foreign  body  may  cauce  an  acute  or 
a  low  and  protracted  form  of  sepsis; 
be  encapsulated  and  retained  for 
months  or  years ;  or  be  extruded 
through  the  wound,  or  into  the  hollow 
viscera ;  or,  more  rarely,  through  the 
cicatrix.  The  accident  has  occurred 
despite  repeated  counts  of  sponges,  and 
the  plan  of  attaching  tapes  to  the 
sponges  is  shown  to  be  fallible.  In  a 
number  of  instances  a  sponge  was  torn 
in  two  during  the  operation.  It  is  ad- 
vised that  abdominal  operation  be  done 
with  the  simplest  equipment  practicable. 
The  responsibility  rests  with  the  nurse 
or  assistant  charged  with  the  enumera- 
tion of  the  sponges  and  instruments, 
not  the  operator.  Schachner  (Annals 
of  Surg.,  Nov.,  1901). 

In  1'899  the  writer  found  records  of 
108  cases,  and  in  1904  he  had  collected 
88  more — a  total  of  236  cases,  not  to 
mention  a  number  of  others  in  which 
the  correct  details  are  not  known. 
Netigebauer  (Archiv  fiir  Gynak.,  Bd. 
Ixxxii,  F.  V.  Winckel  Nu.,  1907). 

When  one  or  more  objects  have  been 
left  behind  in  the  peritoneal  cavity 
the  patient  may  go  on  to  recovery,  but 
usually  there  is  a  persistent  nausea 
and  a  higher  degree  of  local  tender- 
ness and  discomfort  than  we  can 
usually  account  for,  and  the  persist- 
ence of  such  condition  of  nausea  and 
distress  at  the  site  of  an  operation 
may  lead  one  to  feel  that  it  is  best  to 
reopen  the  abdominal  cavity  and 
search  for  a  foreign  body  which  has 
been  left*  behind.  This  postoperative 
complication  is  not  so  easily  guarded 
against  as  one  might  imagine;  but 
gauze  for  intra-abdominal  work,  to 
which  tapes  have  been  attached  in 
the  form  of  a  long  roll,  one  end  of 


22 


ABDOMEN,   SURGERY  OF    (MORRIS). 


which  is  always  left  outside  of  the 
abdomen  to  guard  against  accident, 
should  be  employed. 

Case  in  which,  after  removing  a 
piece  of  gauze  which  had  remained  in 
the  cavity  for  two  months,  the  writer 
was  obhged  to  resect  the  intestine  in 
three  places,  the  patient  eventually- 
making  a  perfect  recovery.  He  reports 
17  cases  in  which  gauze  was  left  after 
operation,  only  one  of  which  terminated 
fatally.  In  9  the  foreign  body  was  dis- 
charged spontaneously,  in  8  removed 
by  operation,  but  in  none  were  such 
extensive  lesions  found  as  in  the  case 
reported.  Kayser  (Archiv  fiir  Gynak., 
Bd.  Ixviii,  Hft.  2,  1903). 

Case  of  simulated  ovarian  tumor 
which  proved  on  operation  to  be  a 
completely  encysted  compress,  relic  of 
some  former  surgical  intervention.  Ex- 
periments on  animals  confirmed  the 
possibility  that  an  overlooked  sterile 
compress  can  be  thus  enc3-sted,  and 
also,  further,  that  such  a  compress  may 
work  its  way  through  into  the  gut  and 
be  spontaneously  evacuated.  He  has 
found  41  cases  on  record  of  a  compress 
having  been  left  in  the  abdomen.  In  9 
the  patients  died  soon  after,  wath 
symptoms  of  peritonitis.  Riese  (Ar- 
chiv fiir  klin.  Chir.,  Bd.  Ixxiii,  Xu.  4, 
1904). 

Case  of  an  old  woman  who  had  re- 
tained a  long  Terrier  compression  for- 
ceps (22  cm.  long)  in  her  peritoneal 
cavity  for  seven  years.  She  complained 
of  pains  in  the  abdomen  and  noted  a 
projecting  point  of  some  sort  at  the 
lower  part  of  the  abdominal  wall.  The 
forceps  could  be  felt  in  Douglas's 
space  by  rectal  examination,  and  it  was 
removed  through  a  posterior  vaginal 
incision.  The  patient  made  a  good  re- 
covery. Grousdieff  (Roussky  Vratch, 
July  29,  1906). 

The  writer  attaches  each  compress  or 
piece  of  gauze,  used  after  the  abdomen 
is  opened,  to  the  wire  basket  in  which 
they  were  sterilized.  Only  large  com- 
presses of  several  layers  of  gauze  are 
used,  and  to  each  compress  is  attached 
a  piece  of  narrow  tape  over  six  feet 
long.  The  free  ends  of  the  tapes  are 
passed  through  the  meshes  of  the  wire 


basket  and  tied  together.  The  basket 
may  be  placed  on  the  floor  under  the 
table.  The  tapes  are  not  annoying 
after  one  is  used  to  them.  Wechsberg 
(Zentralbl.  fur  Gynak.,  Xu.  12,  1907). 
Case  in  which  a  patient  apparently 
secreted  portions  of  gauze  in  her 
vagina  after  an  abdominal  operation, 
with  the  view  of  misleading  her  family 
attendant  into  the  belief  that  they  had 
been  left  in  the  abdomen  after  opera- 
tion and  were  escaping  through  a  fis- 
tulous opening.  The  writer  uncovered 
the  trick,  and  reports  the  case  as  pos- 
sibly throwing  a  sidelight  on  the  sub- 
ject of  some  alleged  cases  of  foreign 
bodies  in  the  abdomen,  and  as  a  source 
of  blackmail.  M.  F.  Porter  (Jour. 
Indiana  State  Med.  Assoc,  April, 
1908). 

Secondary  hemorrhage  as  a  post- 
operative complication  occurs  more 
often  in  abdominal  surgery  than  else- 
where, because  of  violent  vomiting, 
which  dislodges  sutures  and  liga- 
tures. This  must  always  be  borne  in 
mind,  and  we  avoid  the  accident  by 
introducing  as  few  mass  ligatures  as 
possible,  and  ligating  vessels  sep- 
arately. Very  many  cases  of  second- 
ary hemorrhage  have  occurred  after 
ligation  of  the  broad  mesentery  of 
the  appendix,  or  of  a  broad  ligament, 
because  contraction  of  the  psoas  and 
iliac  muscles,  in  addition  to  the  other 
muscular  contractions  in  vomiting, 
has  a  tendency  to  broaden  out  the 
peritoneal  base  and  force  off  such 
ligatures,  unless  they  have  been  tied 
with  caution.  Secondary  hemorrhage 
occurs  also  when  violent  vomiting  has 
caused  fine  sutures  of  silk  or  thread  to 
cut  out  under  tension,  and  for  this  rea- 
son the  author  favors  sutures  of  larger 
caliber  than  are  commonly  employed. 
Where  large  vessels  have  been 
opened,  and  secondary  hemorrhage 
occurs  marked  by  the  ordinary  signs 
of      increasing     thirst,      restlessness, 


ABDOMEN,    SURGERY   OF    (MORRIS). 


23 


pallor,  pain  and  rapid  pulse,  we  must 
reopen  the  abdominal  cavity  for 
securing  bleeding  points  and  remov- 
ing blood,  and  this  is  usually  a  very 
dangerous  procedure  because  of  the 
condition  of  the  patient,  requiring 
preparation  for  direct  infusion  of 
blood  or  introduction  of  intravenous 
saline  solution  at  the  moment  the 
abdomen  is  reopened.  Another  form 
of-  secondary  hemorrhage  occurring 
after  operation  is  common  when  the 
force  of  the  arterial  pulse  is  sufficient 
to  give  I'is  a  tcrgo  to  blood  in  veins 
torn  in  separating  adhesions,  and 
which  are  not  bleeding  much  at  the 
time  when  the  operation  is  completed. 

Since  von  Eiselberg  published  his 
first  observation  on  gastric  and  intes- 
tinal hemorrhages  following  operations 
(1899)  many  other  authors  have  writ- 
ten on  the  subject.  Most  of  them  are 
in  accord  with  A'on  Eiselberg's  theory 
of  the  causation  of  these  hemorrhages; 
namel3%  that  they  result  from  throm- 
botic and  embolic  processes  in  the 
territory  of  the  gastrointestinal  circu- 
lation. 

The  author  has  studied  30  cases  of 
gastric  and  intestinal  hemorrhages  after 
operation.  All  these  cases  were  oper- 
ated upon  for  acute  or  chronic  ab- 
dominal conditions ;  17  patients  died 
after  the  operative  procedures.  At  the 
post-mortem  examinations,  in  most  of 
the  cases,  very  little  could  be  found  to 
account  for  the  ofttimes  profuse  bleed- 
mg  during  life.  It  may  m  general 
be  stated,  however,  that  the  anatomical 
alterations  consist  in  hemorrhages  into 
the  mucous  membrane,  hemorrhagic 
erosions,  or  small  ulcers.  These  lesions 
are  to  be  found  in  the  stomach  or  duo- 
denum ;  the  remainder  of  the  intestinal 
tract  is  usually  negative.  These  ana- 
tomical changes  result  from  injury  to 
the  corresponding  blood-vessels.  Such 
injury  may  be:  1.  Blocking  of  the 
veins  from  retrograde  emboli  or  from 
a  progressing  venous  thrombosis.  2. 
Paralysis  of  the  circulation  in  localized 


areas,  the  eflfect  of  the  circulating 
poison  or,  in  rare  cases,  the  result  of 
an  affection  of  the  central  nervous 
system. 

The  gastrointestinal  hemorrhages  oc- 
cur most  frequently  in  the  first  three 
days  after  operation.  When  the  con- 
dition from  which  the  patient  is  suf- 
fering is  not  fatal  the  gastric  or  in- 
testinal lesions  rapidly  get  well ;  the 
lesions  are  thus  not  true  ulcers.  The 
prognosis  in  individuals  suffering  from 
profuse  hemorrhages  is,  in  the  presence 
of  a  general  infection,  very  poor.  J. 
R.  von  Winniwa-rter  (Archiv  f.  klin., 
Bd.  xcv,  Theil  1,  1911;  Amer.  Jour,  of 
Surg.,  Sept.,  1911). 

After  any  aseptic  abdominal  opera- 
tion considerable  blood  may  escape  into 
the  peritoneal  cavity  without  causing  a 
great  degree  of  disturbance  beyond 
the  increase  in  local  pain,  which  is  the 
characteristic  sign  of  such  hemorrhage. 
Aseptic  blood  in  the  peritoneal  cavity  is 
still  in  the  circulation  in  a  way,  be- 
cause the  peritoneal  cavity  is  a  lymph- 
chamber,  and  the  serous  remains  of 
the  blood  which  escape  in  the  course 
of  coagulation  are  taken  up  into  the 
blood  circulation  again.  Morphine 
lessens  the  hemorrhage  and  strych- 
nine increases  it.  Bearing  these  facts 
in  mind,  we  may  sometimes  give  the 
dangerous  morphine  to  advantage,  or 
withhold  the  strychnine  unless  it  is 
greatly  required. 

The  writer  reports  5  cases  of  collapse 
of  the  lungs  after  abdominal  opera- 
tions. The  symptoms  are  sudden  dysp- 
nea and  C3'anosis,  with,  perhaps,  pain 
in  the  lower  part  of  the  chest  and  a 
slight  cough.  On  the  same  side  as  the 
operation  there  is  dullness  at  the  base, 
with  weakness  of  the  breath  sounds, 
which  ultimately  become  inaudible. 
The  movements  on  the  healthy  side,  on 
the  other  hand,  are  exaggerated,  and 
the  lung  apparently  becomes  enlarged 
through  a  process  of  compensation. 
Pasteur  (London  Lancet,  Oct.  8,  1910). 


24 


ABDOMEN,   SURGERY   OF    (MORRIS). 


TOILET  OF  THE  PERITO- 
NEUM.— The  peritoneum  protects 
itself  so  well,  if  given  opportunity, 
that  we  need  pay  very  little  atten- 
tion to  securing-  asepsis  of  any  part 
of  the  abdominal  cavity  while  we 
are  at  work.  If  pus  escapes  upon 
normal  peritoneum  when  abscesses 
are  opened,  it  commonly  causes  no 
harm,  even  though  it  be  left  upon  the 
peritoneum  when  we  are  through 
with  the  operation.  There  are  two 
reasons  for  this.  Bacteria  are  chiefly 
at  work  in  the  tissues  rather  than  in 
the  pus  proper,  and  the  latter  is  often 
practically  sterile,  even  in  the  presence 
of  advancing  infection.  By  pus  I  do 
not  mean  intraperitoneal  fluids  teem- 
ing with  bacteria,  but  these  are  for 
the  most  part  not  walled  in  like  pus. 
The  principle,  however,  of  treatment 
is  practically  the  same ;  for  where 
such  fluids  occur  any  special  effort  at 
securing  asepsis  would  be  futile, 
and,  more  than  that,  likely  to  be 
harmful. 

We  may  quickly  arrange  drainage 
for  such  septic  fluids,  but  efforts  at 
wiping  or  washing  them  out  are  apt 
to  lead  to  injury  of  the  endothelial 
covering  of  the  peritoneum,  and  to 
defeat  the  object  of  our  good  inten- 
tions. 

When  fluids  carrying  bacteria  or 
sterile  pus  in  quantity  should  be  re- 
moved, it  is  best  to  do  it  very  gently 
by  quick  absorption  into  masses  of 
absorbent  gauze,  rather  than  by 
sponging  or  flushing,  and  we  take 
good  care  at  the  same  time  to  avoid 
the  wiping  which  injures  endothe- 
lium. Where  stomach  or  bowel  con- 
tents are  likely  to  escape  in  the 
course  of  an  operation,  it  is  well  to 
protect  the  field  with  absorbent 
gauze,  but  such  gauze  adheres  quickly 


and  firmly  to  normal  peritoneum,  with 
injury  to  its  endothelium.  Where  we 
can  apply  the  resource  of  placing  a 
layer  of  rubber  dam  between  perito- 
neum and  gauze  while  we  are  at  work, 
we  guard  the  peritoneum  in  the  best 
way.  The  peritoneum,  while  pro- 
tecting itself  remarkably  against  in- 
fective material,  is  disabled  by  the 
washing  and  wiping  commonly  em- 
ployed, and  particularly  by  the  appli- 
cation of  germicides,  almost  any  one 
of  which  in  the  peritoneal  cavity  is 
productive   of  damage. 

A  peritoneum  which  would  be  per- 
fectly safe,  even  though  considerable 
septic  fluid  were  left  upon  it,  may 
when  disabled  start  out  on^  a  career 
of  infection  which  would  have  been 
avoided  if  we  had  not  tried  in  a  crude 
way  to  make  the  peritoneum  ideally 
clean.  In  the  vicinity  of  the  focus  of 
infection  within  the  peritoneal  cavity 
a  local  hyperleucocytosis  becomes 
established  with  extreme  rapidity, 
and  this  does  away  with  the  necessity 
for  much  of  the  work  in  toilet  of  the 
peritoneum  described  by  authors  in 
general. 

There  are  occasions  in  which  it  is 
desirable  to  evacuate  very  large 
quantities  of  pus  or  septic  fluids 
quickly,  and  for  this  purpose  hydro- 
gen dioxide  may  be  used,  provided 
that  all  exits  are  kept  free,  and  that 
the  only  peritoneum  with  which  it 
comes  in  contact  is  peritoneum  al- 
ready damaged.  Hydrogen  dioxide 
damages  normal  peritoneum  instan- 
taneously, and  is  to  be  used  only 
where  the  peritoneum  has  already  suf- 
fered great  damage,  but  in  such  situa- 
tions it  throws  out  pus  and  septic  fluids 
in  a  great  foaming  mass,  and,  this 
mass  removed,  saline  solution  may- 
follow;  leaving  the  cavity  very  clean. 


ABDOMEN,    SURGERY    OF    (MORRIS). 


25 


While  hydrogen  dioxide  is  germicidal, 
its  value  rests  in  its  mechanical  effect 
in  throwing  out  albuminous  fluids  and 
debris  rapidly,  rather  than  in  securing 
asepsis  where  it  is  not  needed,  and 
when  efforts  to  secure  it  through  the 
use  of  germicides  are  damaging. 
For  most  cleansing  purposes  in  the 
peritoneal  cavity  physiologic  salt 
solution  is  the  best,  although  even 
that  is  to  be  used  with  caution.  If  it 
is  not  employed  with  too  much  force 
or  removed  too  vigorously  it  has  a 
field  of  value.  The  solution  of  nine- 
tenths  of  1  per  cent.,  isotonic  for 
human  blood-serum,  is  more  benign 
than  the  commonly  emplo3^ed  six- 
tenths  of  1  per  cent,  which  is  isotonic 
for  frogs'  blood,  and  which  had  its 
origin  in  the  laboratories.  The  saline 
solution  should  be  sterilized  by  boiling. 

Sterile  water,  even  though  boiled, 
should  never  be  used  within  the 
peritoneal  cavity  unless  it  contains 
salt.  The  reason  why  water  without 
salt  should  not  be  used  is  because  it 
is  corrosive.  Its  corrosive  nature 
may  be  noted  at  once  by  dropping  it 
in  the  eye,  which  leads  to  immediate 
smarting  and  burning  of  the  conjunc- 
tiva. Water  without  salt  is  so 
destructive  to  delicate  tissues  in 
laboratory  work,  and  the  fact  is  so 
well  known,  that  it  is  a  strange  omis- 
sion on  the  part  of  many  authors  to 
neglect  to  state  the  dangerous  char- 
acter of  water  without  salt. 

The  reason  why  even  sterile  pure 
water  is  corrosive  is  because  an 
osmosis  of  salts  fro-m  the  body  cells 
immediately  occurs  in  the  presence 
of  water  not  containing  those  salts 
in  the  proportion  in  which  they  are 
found  in  the  body  cells.  Chloride 
of  sodium,  however,  being  the  chief 
salt  involved,  is  the  only  one  which 


we  need  to  add  to  the  water  for  prac- 
tical purposes  in  routine  work. 

Dawbarn  poured  milk  representing 
septic  fluid  into  the  peritoneal  cavity 
of  a  cadaver,  and  then  set  to  work 
to  find  the  best  way  to  get  all  of 
the  milk  out  again,  and  after  a 
very  great  deal  of  flushing  and  spong- 
ing found  that  some  milk  still  re- 
mained. 

This  showed  how  impossible  it  is 
to  remove  the  septic  fluid  by  any 
mechanical  toilet  of  the  peritoneum, 
and  demonstrates  the  degree  of 
damage  to  peritoneum  which  will 
occur  incidentally  through  our  efforts. 
Consequently  the  toilet  of  the  peri- 
toneum is  best  left  in  part  to  the 
peritoneum  itself,  aided  by  such 
resources  as  we  have  learned  do  not 
cause  damage.  As  the  result  of 
experimentation  some  authors  have 
closed  the  peritoneal  cavity  com- 
pletely without  drainage  in  cases  in 
which  it  was  known  that  some  septic 
areas  remained  behind,  depending 
upon  the  peritoneum  to  dispose  of 
any  sepsis  after  the  chief  focus  of 
infection  had  been  removed.  While 
primary  union  often  occurs  in  such 
cases,  the  author  believes  that  at 
the  present  time  it  is  best  to  use 
small  capillary  drainage  apparatus 
for  removing  culture  fluids  from  the 
septic  site. 

DRAINAGE  OF  THE  PERI- 
TONEAL CAVITY.— Because  of  at- 
mospheric pressure  upon  the  abdom- 
inal contents,  any  free  fluid  within 
the  peritoneal  cavity  has  a  tendency 
to  follow  the  line  of  least  resistance 
to  the  surface,  and  if  this  fluid  is 
given  direction  by  way  of  small  capil- 
lary drains  we  fulfill  the  general  indi- 
cations in  drainage,  but  posture  of 
the  patient  is  an  aid  under  some  cir- 


26 


ABDOMEN,    SURGERY   OF    (MORRIS). 


cumstances;  and  the  Fowler  position, 
in  which  the  upper  part  of  the  body 
is  raised  in  bed  to  an  angle  which 
will  allow  fluids  to  gravitate  to  the 
drain  in  the  lower  part  of  the 
abdomen,  is  at  times  very  useful. 
The  only  objection  to  the  Fowler 
position  is  the  call  for  rather  more 
work  on  the  part  of  the  heart  in  u 
very  weak  patient. 

In  tlie  upper  part  of  the  abdomen 
we  have  a  natural  mechanical  situa- 
tion, aiding  drainage  from  the  bile- 
tract  region,  in  what  is  known  as 
Morison's  pouch,  the  space  between 
the  liver,  above,  and  the  stomach  and 
colon,  below.  Blood,  bile  or  septic 
fluids  escaping  into  this  pouch  have 
a  tendency  to  make  their  way  directly 
to  the  surface  at  this  point,  instead 
of  spreading  into  the  general  peri- 
toneal cavity  below,  and  this  tendency 
is  so  marked  that  a  very  little  capil- 
lary drainage  carried  to  the  bile-tract 
region  suffices  to  clear  the  area  of 
culture  media.  It  even  allows  us  to 
do  away  with  suturing  the  common 
bile-duct  in  many  cases  in  which  this 
has  been  opened  for  removing  a  cal- 
culus. 

Abdominal  drainage  is  well  con- 
ducted by  any  of  the  means  described 
under  the  head  of  drainage  apparatus, 
and  the  author  feels  that  it  is  always 
best  to  employ  capillary  drainage, 
rather  than  drainage  through  tubes 
which  carry  no  gauze  wick.  When  a 
tube  without  gauze  wick  is  filled  with 
fluid,  the  column  of  fluid  in  the  tube 
exerts  hydrostatic  pressure  of  con- 
siderable degree,  which  is  met  by  the 
atmospheric  pressure  of  the  viscera, 
to  be  sure,  but  drainage  through  a 
simple  tube  cannot  be  so  free  as  when 
fluids  are  guided  through  the  tube  by 
absorbent  gauze  with  its  high  degree 


of  capillary  power.  Drainage  appara- 
tus should  be  carried  as  little  as  pos- 
sible among  intestinal  loops,  because 
such  drainage  apparently  acts  as  a 
foreign  body,  and  the  peritoneum 
rapidly  throwing  out  lymph  because 
of  the  offense  seals  in  such  drainage 
apparatus  and  deprives  it  quickly  of 
its   usefulness. 

If  the  abdominal  work  carries  us 
to  the  pelvis,  there  is  sometimes 
an  inclination  for  the  surgeon  to 
add  vaginal  drainage,  because  the 
Douglas  pouch  represents  the  lowest 
part  of  the  abdominal  cavity,  and  one 
would  naturally  feel  that  fluids  would 
all  gravitate  to  this  lowest  point. 
This  is  not  quite  true,  however,  in 
practice,  as  atmospheric  pressure  has 
a~  tendency  to  force  even  pelvic  fluids 
to  the  midline  incision  in  the 
abdomen,  with  or  without  encourage- 
ment from  capillary  drains,  and  the 
advantage  of  depending  upon  drain- 
age through  an  abdominal  incision 
rather  than  through  a  vaginal  incision 
depends  upon  the  comparative  ease 
with  which  the  area  of  the  abdominal 
incision  is  kept  aseptic.  Drainage  in 
the  vaginal  region  is  in  an  area  much 
more  difficult  of  maintaining  in  a 
degree  of  relative  asepsis. 

The  author  formerly  felt  that  it 
was  an  advantage  to  insert  drainage 
apparatus  at  more  than  one  point  in 
the  abdominal  wall  at  points  that 
seemed  natural  places  for  collection 
of  peritoneal  fluid,  but  of  late  years, 
in  a  series  of  many  hundreds  of 
abdominal  operations  sufficient  to 
demonstrate  the  real  requirements, 
he  has  found  that  one  point  for  drain- 
age in  the  lower  abdomen  will  suffice, 
and  the  only  additional  point  used  for 
drainage  for  many  years  has  been  in 
reference  to  Morison's  pouch,  which 


ABDOMEN,   SURGERY   OF    (MORRIS). 


27 


amounts  practically  to  a  separate 
cavity  more  distinct  than  the  cavity 
of  the  pelvis  so  far  as  the  cjuestion  of 
the  nccessitv  for  drainag'e  devices  is 
concerned.  We  need  to  give  aid  to  a 
single  incision  drainage  at  times  by 
the  addition  of  posture. 

In  order  to  carry  out  the  principles 
of  capillary  drainage  it  is  essential  for 
one  to  be  familiar  with  the  mechanical 
principles  involved,  and  to  make  fre- 
quent change  of  the  external  mass  of 
gauze  to  keep  the  capillary  drain  at 
work  within  the  abdomen.  In  cases 
in  which  fluids  drained  from  the 
peritoneal  cavity  are  irritating  to  the 
skin,  the  skin  may  be  dried  tem- 
porarily, and  then  covered  in  the 
vicinit}^  with  a  thin  layer  of  collodion 
or  of  vaselin.  In  addition  to  the 
drain  for  the  peritoneal  cavity,  it  is 
important,  on  closing  the  abdominal 
incision,  to  leave  a  tiny  wick  drain 
for  twenty-four  hours,  extending  be- 
tween the  muscle  layer  and  the  skin. 
This  can  rest  between  the  sutures  in 
such  a  way  as  to  interfere  not  at  all 
with  final  primary  union.  At  the  end 
of  twenty-four  hours,  or  at  the  time 
of  the  first  dressing,  it  may  be  pulled 
out,  and  will  be  found  to  have  drained 
out  as  a  rule  quite  a  little  serum  or 
free  fat,  or  both,  which  would  have 
been  a  menace  as  a  culture  medium. 
Excepting  in  patients  with  a  very 
thin  adipose  layer,  it  is  well  to  make 
it  a  rule  to  introduce  this  tiny  drain 
at  any  convenient  point  between  the 
sutures,  and  to  remove  it  on  the  fol- 
lowing day. 

HEMOSTASIS.— A  few  technical 
points  belong  to  hemostasis  in  abdom- 
inal surger}^  Where  it  is  possible  to 
use  torsion  instead  of  ligatures — and 
this  covers  very  much  of  the  field — 
we  can  avoid  ligatures,  the  presence 


of  which  causes  the  peritoneum  to 
throw  out  plastic  lymph  in  the  vicin- 
ity for  its  protection,  very  much  as 
the  mollusk  throws  a  layer  of  nacre 
over  a  grain  of  sand  in'  the  shell. 
Where  it  is  necessary  to  use  ligatures 
we  avoid  including  much  mass  in  the 
ligature,  because,  the  larger  the  mass, 
,the  greater  the  tendency  for  the  peri- 
toneum to  throw  out  reparative 
lymph  which  will  lead  to  adhesion 
formation  subsequently.  We  have 
also  to  remember  that  the  efforts  of 
vomiting  after  an  abdominal  opera- 
tion have  a  tendency  to  pull  off 
certain  ligatures,  and  consequently 
we  must  leave  a  considerable  mass  of 
tissue  outside  of  the  knot.  Such 
mass  of  tissue  is  not  likely  to  slough, 
as  some  operators  fear,  because  it  is 
kept  alive  by  lymph  circulation  in  the 
vicinity,  and  has  a  tendency  to  grad- 
ually becorne  absorbed  in  a  very 
benign  way,  because  of  the  fact  that 
it  is  tissue  belonging  to  the  indi- 
vidual. Hemostasis  of  the  cut  margins 
of  the  alimentary  tract  cannot  readily 
be  obtained  by  ligating,  and  conse- 
quently we  employ  the  suture  here 
instead,  for  the  most  part,  and  snugly 
drawn  running  sutures  suffice  for  the 
purpose. 

EXTERNAL  INCISIONS.— The 
ultimate  success  of  an  abdominal 
operation  often  depends  largely  upon 
the  choice  of  the  external  incision, 
and  we  have  two  especial  points  to 
bear  in  mind :  consideration  of  the 
best  route  for  getting  to  any  objective 
point  within  the  abdominal  cavity, 
and  at  the  same  time  the  best  way 
for  avoiding  imperfect  repair  of  the 
abdominal  wall  and  unsightly  scars. 

This  includes  a  consideration  of 
avoiding  nerves  which  supply  mus- 
cles, because  a  temporary  or  perma- 


28 


ABDOMEN,    SURGERY    OF    (MORRIS). 


nent  paralysis  of  certain  abdominal 
muscles  was  a  very  annoying  post- 
operative complication  before  sur- 
geons began  to  give  attention  to  this 
matter.  To  reach  an  objective  point 
in  the  peritoneal  cavity,  and  at  the 
same  time  avoid  the  complication  due 
to  muscles  cut  transversely,  we  may 
practically  cover  the  ground  by  stat- 
ing that  it  is  well  to  plan  to  make 
separate  division  of  each  layer — skin, 
adipose  tissue,  fascia,  muscle  and 
parietal  peritoneum — and,  further,  to 
make  blunt  dissection  as  far  as  pos- 
sible of  each  muscle,  even  though 
this  sometimes  leads  to  openings 
crossing  each  other  at  somewhat  dif- 
ferent angles.  Stretching  of  the 
muscle  wound  with  the  fingers,  how- 
ever, does  away  with  most  of  the 
awkwardness  of  a  situation  where 
split  muscles,  after  blunt  dissection,  as 
it  is  called,  lie  at  different  angles. 

When,  for  any  reason,  it  becomes 
necessary  to  cut  transversely  across 
a  muscle  we  must  mark  well  the 
point  at  which  such  transverse  inci- 
sion was  made  for  the  purpose  of 
making  accurate  repair  subsequently, 
otherwise  the  muscles  acting  in  their 
lines  of  traction  during  the  course  of 
the  operation  will  smooth  out  angles 
more  by  transverse  incisions,  and  it  is 
difficult  to  restore  these  angles  again. 
On  general  principles  our  incisions 
are  to  be  made  directly  over  the 
objective  point,  but  because  of  the 
ease  with  which  an  incision  is  made 
into  the  abdominal  cavity  in  the 
median  line,  and  the  ease  with  which 
such  an  incision  is  repaired,  the  mid- 
line incision  should  be  used  for  per- 
haps the  larger  part  of  our  abdominal 
work. 

The  size  of  incisions  will  depend 
largely  upon  the  operator.    One  must 


make  as  large  an  incision  as  he  needs 
for  working  freely  and  safely,  but,  if 
experience  allows  an  operator  to 
make  his  incisions  shorter  and  shorter 
safely  in  any  particular  field  of 
abdominal  work,  the  patient  will  have 
the  advantage  of  less  danger  from 
subsequent  hernia,  less  shock,  and 
less  noticeable  scars.  Small  incisions 
are  dangerous  for  the  beginner,  and 
plenty  of  room  is  desirable  on  his 
account,  but  he  may  adopt  the  middle 
ground  of  beginning  with  a  compara- 
tively small  incision,  and  then  enlarg- 
ing it  as  occasion  requires. 

If  the  abdomen  requires  opening-  in 
two  dift'erent  localities  at  the  same 
sitting,  there  is  frequently  an  advan- 
tage in  making  two  or  more  small 
separate  openings,  rather  than  ex- 
tending a  large  one  to  reach  distant 
points,  such  as  often  occurs  in  cases 
of  intestinal  obstruction,  where  one  is 
not  sure  of  the  point  of  the  obstruc- 
tion. If  through  the  first  incision,  in 
a  case  of  obstruction,  one  does  not 
readily  reach  the  point  at  which  the 
constriction  occurs,  he  is  likely  to  add 
much  more  to  the  serious  condition 
of  the  patient  if  he  makes  a  large 
incision  and  pulls  the  bowel  out  from 
that  than  he  is  if  he  makes  more  than 
one  incision  small,  and  then  passes 
the  bowel  between  his  fingers  at  that 
point  without  drawing  it  out  upon  the 
abdominal  wall.  Special  incisions 
will  be  noted  in  connection  with  cer- 
tain operations,  the  above  covering 
only  a  general  principle. 

When  we  have  occasion  to  open 
the  abdomen  at  the  site  of  a  former 
operation,  it  is  well  to  carry  the  inci- 
sion through  normal  skin  on  either 
side  of  the  scar  line  for  two  reasons : 
because  of  the  advantage  of  removing 
the   scar   tissue  in   some   cases,   and 


ABDOMEN,    SURGERY   OF    (MORRIS). 


29 


because  in  opening"  at  the  site  of  an 
old  scar  one  may  run  across  adhesions 
of  abdominal  viscera  of  which  he  was 
not  aware,  and  they  may  l)e  injured. 
The  safe  way  for  entering-  along  the 
site  of  an  old  scar,  and  for  leaving  the 
viscera  in  good  condition  for  repair 
subsequently,  is  to  go  down  through 
normal  tissue  on  either  side  of  the  scar 
until  muscle  sheath  is  definitely 
reached,  and  then  snipping  muscle 
sheath  until  the  muscle  beneath  is  seen. 
The  sheath  can  then  be  opened  freely 
on  either  side  of  the  scar  without  dan- 
ger. If  there  is  any  question  about 
adhesions  being  present  at  just  this 
point  of  dangerous  character,  we  ex- 
tend the  incision  through  the  sheath  of 
muscle  to  some  point  above  or  below 
the  scar,  where  we  may  enter  the  peri- 
toneal cavity  at  a  point  free  from  ad- 
hesions, being  extended  at  a  free  point 
large  enough  to  admit  the  finger.  The 
finger  is  then  carried  back  along  the 
peritoneal  side  of  the  scar  line,  and 
adhesions  if  present  are  separated. 
This  having  been  done,  the  posterior 
sheath  of  the  muscle  and  transversalis 
fascia  and  peritoneum  are  safely  cut 
along  the  entire  line  of  the  scar,  and 
the  parts  left  in  excellent  position  for 
correct  apposition  subsequently. 

One  must  always  be  on  guard 
against  small  hernial  protrusions  into 
scar  sites,  and  a  small  knuckle  of 
bowel  may  be  adherent  in  such  pro- 
trusions without  having  leci  to  symp- 
toms sufficient  for  one  to  suspect  its 
presence.  Ordinarily,  on  reaching  the 
peritoneum  or  subperitoneal  fat,  it  is 
not  necessary  to  pick  it  up  and  divide 
between  forceps,  if  one  has  reason  to 
believe  that  no  adhesions  occur  at 
that  point.  Under  ordinary  circum- 
stances, the  various  la3^ers  of  the 
abdominal  wall  having  been  opened 


down  to  the  peritoneum,  or  peritoneal 
or  subperitoneal  fat,  these  structures 
may  be  made  tense  between  two 
lingers  of  one  hand,  and  the  points  of 
scissors  then  introduced  into  this 
tense  area  nearly  parallel  with  the 
plane  of  the  abdominal  wall,  a  neat 
entrance  into  the  peritoneal  cavity  is 
made  with  celerity.  This  opening  can 
then  be  enlarged  to  any  desired  extent 
with  the  scissors,  or  in  many  cases  by 
stretching. 

Closure  of  the  abdominal  incision 
may  also  be  described  in  a  general 
way  to  cover  most  of  the  principles 
involved.  The  first  suture  of  the 
peritoneal  incision  should  consist  of 
the  finest  catgut,  because,  the  smaller 
the  strand  of  catgut,  the  less  peri- 
toneal irritation  from  the  suture,  and 
consequently  less  tendency  to  adhe- 
sions of  the  omentum  which  reaches 
out  to  wall-in  points  of  irritation 
within  its  range.  A  fine  strand  of 
catgut  is  also  a  distinct  advantage 
along  the  line  that  would  be  touched 
by  the  liver,  which  slides  along  the  ab- 
dominal wall  with  each  respiratory 
movement. 

Suturing  the  incision  in  the  ab- 
dominal wall  in  layers  gives  a  more 
satisfactory  and  stronger  looking  wound 
histologically  than  the  en  masse  suture. 
Wounds  sutured  in  layers  Were  the 
stronger  after  two  weeks,  the  strength 
of  the  scar  having  been  tested  by  an 
actual  pull.  Judged  from  a  histologic 
study,  the  suture  in  layers  is  also  more 
desirable  than  the  suture  en  masse  be- 
cause in  this  way  in  the  process  of 
repair  the  strong  trabecular  tissue  aris- 
ing by  proliferation  from  the  fascia 
united  with  tissue  of  its  own  kind, 
thereby  increasing  the  strength  of  the 
scar  and  decreasing  the  time  necessary 
for  repair. 

Violent  manipulations  of  the  edges  of 
an  abdominal  incision  should  be  avoided 
with  the  same  care  as  has  been  recog- 


30 


ABDOMEN,    SURGERY   OF    (MORRIS). 


nized  as  essential  to  good  results  in  the 
handling  of  the  intestines  or  stomach. 
Murphy  (Boston  Med.  and  Surg.  Jour., 
.  March  7,  1907). 
In  experimental  work  with  animals 
in  the  course  of  which  the  author 
closed  peritoneal  incisions  wath  rather 
large  strands  of  catgut  or  silk  for 
the  purpose  of  saving  time,  he  ob- 
served that  adhesions  of  intraperi- 
toneal structures  of  some  sort  along 
the  suture  line  are  practically  uni- 
versal. He  observed  that  the  smaller 
the  strand  of  catgut,  the  less  post- 
operative adhesions  occurred,  and 
although  such  adhesions  commonly 
become  absorbed  they  remain  just 
often  enough  in  practical  surgery  to 
make  it  a  A^ery  general  point  to  avoid 
them  as  much  as  we  can.  Very  little 
strength  indeed  is  required  for  ap- 
proximating peritoneal  margins,  and 
a  suture  which  would  be  absorbed  in 
forty-eight  hours  is  all  that  is  re- 
quired,  and    a   very    small    strand   at 

that. 

In  the  closure  of  an  abdominal  in- 
cision the  writer  overlaps  the  cut  edges 
of  the  rectus  fascia.  The  peritoneum 
is  sutured  with  catgut,  and  the  same 
suture  is  used  to  whip  together  the 
muscle.  On  the  right  side  of  the  wound 
the  fascia  is  separated  back  from  the 
muscle  for  from  1  to  3  cm. ;  likewise 
on  the  left  side.  Tension  sutures  are 
then  introduced  through  the  skin  about 
3  cm.  from  the  edge  of  the  wound, 
passing  through  the  fat  and  the  fascia 
about  1  cm.  from  the  edge,  then  in  and 
out  through  the  fascia  on  the  left  side 
from  1  cm.  to  3  cm.  from  the  edge,  and 
back  through  the  fascia  on  the  right 
side,  then  out  through  the  fat  and  skin 
on  the  left  side.  The  sutures  are 
placed  from  4  to  5  cm.  apart.  Next 
the  edge  of  the  overlapping  fascia  is 
whipped  down  with  chromic  catgut,  and 
the  skin  sutures  with  a  buttonhole  stitch. 
If  the  ends  of  the  tension  sutures  are 
drawn  taut,  the  fascia  will  overlap,  and 
the  whipping  down  of  the  edge  will  be 


facilitated.  Gauze  saturated  with  70 
per  cent,  alcohol  is  placed  over  the 
wound,  and  the  tension  sutures  are  tied 
over  the  gauze.  The  tens'on  sutures 
are  removed  in  from  ten  to  fourteen 
days. 

Lucas-Championniere  conceived  the 
idea  of  overlapping  the  fascia  in  the 
operation  for  inguinal  hernia,  and  em- 
ployed the  method  as  early  as  or  even 
earlier  than  1892.  To  Dr.  Charles  P. 
Noble  is  due  the  credit  of  being  the 
first  to  use,  describe,  and  make  popular 
the  method  in  America.  He  began  to 
overlap  the  fascia  in  1894  and  used  it 
as  a  routine  procedure  in  the  closure  of 
all  abdominal  incisions  after  1896.  The 
method  of  Lucas-Championniere  is  now 
used  with  many  slight  modifications  in 
technique  by  surgeons  all  over  the 
country.  S.  E.  Tracy  (Surg.,  Gynec, 
and  Obstet.,  April  and  Sept.,  1911). 

It  is  the  sheaths  of  the  muscles 
upon  which  we  depend  for  strength 
when  closing  an  abdominal  incision. 
Suturing  of  the  sheaths  of  the  mus- 
cles is  carried  out  neatly  by  using  a 
continuous  suture  of  chromic  gut 
along  the  posterior  sheath  first,  and 
then  returning  along  the  anterior 
sheath  without  introducing  sutures 
into  the  muscle  itself  at  all  when  the 
incision  is  made  in  the  median  line  of 
the  abdomen,  and  the  same  principle 
can  be  used  in  several  parts  of  the 
abdominal  w^all.  Muscle  belly  does 
not  hold  sutures  so  well  as  muscle 
sheaths,  and  there  are  few  situations 
where  it  is  necessary  to  introduce 
sutures  into  the  muscle  belly.  By 
bringing  the  posterior  and  anterior 
sheaths  of  muscles  into  their  respective 
normal  positions,  atmospheric  pres- 
sure carries  the  bellies  together  much 
more  evenly  than  we  could  do  it  with 
sutures. 

Several  fanciful  methods  for  sutur- 
ing the  various  structures,  of  the 
abdominal  wall  have  been  described, 


ABDOMEN,    SURGERY    OF    (MORRIS). 


31 


but  it  is  111  it  necessary  to  dn  aiiylliini;' 
more  than  to  lea\'e  structures  as  we 
found  them  as  nearly  as  possible. 
Where  one  can  catch  the  transversalis 
fascia  along-  with  the  posterior  sheath 
of  a  muscle  in  a  suture,  it  is  well  to 
do  so. 

In  cases  in  which  there  may  be 
need  for  reopening-  the  abdomen  sub- 
scquentl}',  interrupted  sutures  of  the 
muscle  sheath  for  a  part  or  all  of  the 
wa}^  are  of  advantage,  because  then 
we  reopen  onh^  to  the  extent  neces- 
sar3\  AMiere  a  drain  has  been  left  in 
an  incision,  the  suture  running  up  to 
the  drain  may  be  followed  by  a  pro- 
visional interrupted  suture,  if  it  is 
desired  to  close  the  incision  com- 
pletely when  the  drain  is  removed, 
but  this  is  seldom  necessary,  for 
proper  suturing  up  to  the  small 
drains  wdiich  are  now  in  vogue  will 
allow  of  the  walls  falling  together 
naturally  enough  wdien  the  drain  is 
removed. 

One  disadvantage  of  carrying  the 
sutures  through  muscle  tissue  is  the 
danger  of  the  sutures  cutting  through 
such  tissue  wdien  the  patient  vomits. 
This  space  then  fills  with  blood  which 
must  be  replaced  by  new  tissue  cells, 
and  it  usually  is  so  replaced  if  the 
blood,  as  a  culture  medium,  does  not 
become  exposed  to  infection  from  the 
suture,  or  some  other  source.  For 
the  muscle-fascia  suture,  chromic  cat- 
gut, or  kangaroo  tendon  is  desirable, 
because  they  last  so  much  longer  than 
simply  prepared  catgut,  but  not  so 
long  as  to  constitute  a  source  of  irri- 
tation, as  a  rule.  Kangaroo  tendon 
seems  to  be  much  more  benign  than 
chromic  catgut,  and  it  lasts  rather 
longer  in  the  tissues,  unless  the  cat- 
gut has  been  chromicized  in  a  way 
which  makes  it  too  hard. 


A\  liere  one  needs  to  introduce  in- 
terrupted tension  sutures,  there  is 
nothing  better  than  kangaroo  tendon 
passed  through  muscle  sheath,  care- 
fully avoiding  the  fat,  into  which  no 
tension  suture  should  ever  be  intro- 
duced. When  closing  the  adipose 
layer  of  the  abdominal  wall,  it  is  ex- 
tremely important  to  avoid  allowing 
any  sort  of  suture  to  enter  any  fatty 
structure.  The  reason  for  this  is 
because  the  entrance  of  any  suture, 
or  even  the  needle  carrying  the  suture, 
into  the  adipose  layer  allows  free  oil 
to  escape  and  to  follow  the  course  of 
the  needle  or  suture,  and  such  free 
oil,  according  to  tiie  principle  of 
hydrostatics,  wall  begin  to  travel, 
opening  up  lines  for  infection  in  many 
cases. 

Where  a  very  small  amount  of 
oil  is  set  free  along  suture  lines  it  is 
no  doubt  absorbed  in  many  cases, 
but  nevertheless  always  introduces  a 
danger  which  is  unnecessary,  because 
w^e  can  apply  a  principle  in  mechanics 
commonly  overlooked  which  allows 
us  to  do  away  with  any  suturing 
through  an}'  adipose  layer  of  the 
abdominal  wall.  This  principle  is  the 
one  Avhich  is  employed  by  the  boy 
who  lifts  stones  after  pressing  down 
upon  them  a  disk  of  w^et  leather  to 
which  a  string  is  attached  in  the 
middle.  It  is  the  principle  of  making 
use  of  atmospheric  pressure.  When 
the  suturing  of  muscle  sheath  has 
been  completed,  if  the  adipose  layers 
of  the  abdominal  wall  are  then 
pressed  together  with  the  hands,  they 
adhere  firmly  under  atmospheric  pres- 
sure the  moment  that  the  skin  is 
sutured.  It  is  somewhat  difficult  at 
the  end  of  forty-eight  hours  to  sepa- 
rate fatty  tissues  along  the  original 
line,  if  one  has  occasion  for  any  reason 


Z2 


ABDOMEN,    SURGERY    OF    (MORRIS). 


to  re-enter  the  abdominal  cavity.  The 
question  of  suturing  the  adipose  layer 
then  may  be  disposed  of  by  saying 
simply,  Do  not  suture  adipose  tissue 
at  all. 

To  overcome  in  most  instances  the 
difficulties  of  intra-abdominal  operation 
in  stout  patients,  the  writer  resorts  to 
a  large  excision  of  skin  and  fat  from 
the  overweighted  abdominal  wall,  re- 
moving a  skin  section  either  in  the 
transverse  or  in  a  vertical  direction  cor- 
responding to  or  at  right  angles  with 
the  incision,  about  8  or  10  inches  in 
length  by  3  or  4  inches  in  width.  This 
does  away  with  the  thickness  of  the 
wall  down  to  the  fascia,  while  from  the 
fascia  inward  the  difference  between 
different  abdomens  is  not  great.  If  the 
patient  is  excessively  fat,  one  will  then 
naturally  do  a  regular  lipectomy  opera- 
tion. This  serves  the  same  purpose 
and  is  done  the  same  as  the  lesser  pro- 
cedure here  described.  The  writer  em- 
phasizes the  value  of  removing  wedges 
of  skin  and  fat  in  patients  who  are  not 
troubled  with  obesity,  but  simply  and 
solely  for  getting  rid  of  a  part  of  the 
thickness  of  the  abdominal  wall  and 
making  the  field  of  the  operation  more 
accessible. 

An  oval  or  an  elliptical  excision  is 
made,  cutting  right  down  to  the  strong 
fascia  overlying  the  rectus  and  oblique 
muscles.  All  bleeding  vessels  ought  to 
be  carefully  tied.  It  is  a  good  plan  to 
slope  the  edges  of  the  incision  a  little 
inward.  When  this  piece  of  skin  and 
fat  is  removed  the  operator  then  finds 
it  much  easier  to  open  the  abdominal 
wall  and  operate  than  in  a  similar  case 
in  which  he  has  to  retract  this  embar- 
rassing mass  of  tissue  as  well.  The 
writer  closes  such  a  wound  with  a  fine 
catgut  suture,  catching  a  distinct  layer 
of  fascia  about  the  middle  of  the  fat, 
silkworm-gut  sutures  uniting  both  skin 
and  adipose  tissue.  Kelly  (Annals  of 
Surg.,  March,  1911). 

In  suturing  the  skin  the  use  of  the 
subcuticular  suture  avoids  scarring 
with  a  needle,  and  it  also  avoids  the 
danpfer  of  making  stab  cultures  of  the 


Staphylococcus  alhus,  which  is  found 
regularly  as  an  inhabitant  of  the  hair- 
follicles  of  the  skin.  AVhere  very 
heavy  abdominal  walls  are  to  be  sup- 
ported, we  may  fortify  the  skin 
sutures  by  placing  squares  of  zinc 
oxide  plaster  at  a  short  distance  from 
the  line  of  incision  on  either  side  of 
the  incision,  and  then  lacing  these 
squares  together  through  eyelet  holes 
placed  in  the  margins. 

To  avoid  infecting  the  wound  with 
the  lacing,  a  thin  layer  of  dressing  is 
first  placed  next  the  wound,  and  then 
the  squares  of  adhesive  plaster  laced 
together  over  this.  We  thus  avoid 
altogether  the  necessity  for  introduc- 
tion of  deep  through-and-through 
sutures,  which  in  the  past  have  been 
commonly  used  for  supporting  over- 
heavy  abdominal  walls. 

To  avoid  unsightly  scars  of  the 
skin  due  to  stretching  out  and  widen- 
ing of  the  scar  line  after  union  is 
complete,  we  put  a  single  layer  of 
gauze  or  chenille  over  the  line  of 
incision,  and  then  pour  on  collodion. 
This  collodion-gauze  dressing  may 
remain  in  place  for  two  or  three 
weeks  if  one  wishes,  and  it  consti- 
tutes a  very  neat  resource  for  avoid- 
ing scarring  of  the  abdominal  wall  for 
people  who  have  a  perfectly  legiti- 
mate vanity  in  the  matter. 

The  Pfannenstiel  incision  for  lapa- 
rotomy is  commended  by  the  writer, 
who  employed  it  in  150  cases,  ?>6  of 
which  were  cases  of  carcinoma  oper- 
ated by  Wertheim's  method  (removal 
of  the  iliac  glands).  It  is  easy,  the 
liability  to  hernia  is  decidedly  dimin- 
ished, the  mortality  is  probably  less 
than  that  of  the  medi?n  incision,  and 
the  only  contraindications  are  those 
in  which  the  vaginal  route  can  be  used, 
large  fibroids,  and  cases  in  which  there 
are  many  adhesions.  Vertes  (Zen- 
tralbl.  fiir  Gynak.,  Sept.  24,  1904). 


ABDOMEN,    SURGERY    OF    (MORRIS). 


33 


Pfanncnstiel's  incision  may  be  used 
with  good  results  in  the  Wcrthcim 
operation  and  for  the  removal  of 
ovarian  tumors  if  the  cyst  is  punctured. 
It  is  not  suitable  in  suppurative  or 
tuberculous  cases.  It  is  believed  to  have 
important  advantages  over  the  median 
incision  in  many  cases.  Helsted  (Zen- 
tralbl.  fiir  Gynak.,  Bd.  xxxii,  S.  248, 
1908) . 

The  Pfannenstiel  transverse  incision, 
as  shown  by  over  1000  cases,  aflfords  a 
better  ultimate  outcome  than  the  longi- 
tudinal incision,  even  in  cases  with  du- 
bious asepsis.  The  tendency  to  post- 
operative hernia  is  less,  the  patients  are 
able  to  be  up  earlier,  and  the  scar  is 
less  prominent.  Jaschke  (Miinch.  med. 
Woch.,  Nov.   1,   1910). 

Of  581  laparotomies  performed  dur- 
ing two  years  at  the  Tubingen  clinic, 
Pfanncnstiel's  suprasymphyseal  trans- 
verse fascial  incision  was  employed  in 
550.  Where  great  haste  was  indicated, 
as  in  a  ruptured  extra-uterine  preg- 
nancy, the  median  incision  was  used. 
Of  the  entire  number,  84  could  be  re- 
examined. Of  these,  3  showed  herniae 
in  the  scar.  Of  the  entire  number  of 
cases,  418  healed  without  suppuration, 
109  suppurated,  and  23  died.  R.  Klotz 
(Zentralbl.   fiir  Gynak.,  May  21,  1910). 

EXPLORATORY  OPERA- 
TIONS.—  Very  few  exploratory 
operations  should  be  done  in  abdom- 
inal surger)^  The  method  no  doubt 
makes  diagnosis  easier  for  the  sur- 
geon, but  a  more  difficult  matter  for 
the  patient,  and  it  is  highly  important 
to  make  use  of  all  available  diagnostic 
resources  before  taking  active  steps 
in  an  operative  way.  Where  an  ex- 
ploratory operation  really  needs  to 
be  done,  however,  it  is  best  to  make 
as  small  an  incision  as  will  suffice  for 
the  purpose.  There  are  cases,  for 
instance,  in  which  we  need  to  know 
if  adhesions  in  the  bile-tract  region 
are  complicating  a  loose  kidney,  or  an 
appendix  operation;  and  an  explora- 


tory operation,  if  small,  for  the  pur- 
pose of  determining  that  point  is 
frequently  in  order.  Then  again, 
after  traumatisms  and  perforations, 
the  peritoneal  cavity  can  contain 
blood,  chyme,  fecal  matter  or  gas, 
which  might  be  overlooked  if  one 
were  too  conservative  about  making 
explorator}-'  incisions.  In  the  pres- 
ence of  traumatic  shock,  ordinary 
diagnostic  resources  may  fail  us,  and 
lead  us  to  employ  what  older  sur- 
geons are  apt  to  consider  the  resource 
of  the  tyro,  namely,  the  exploratory 
incision. 

PERITONEAL  ADHESIONS.— 
Perhaps  the  most  potent  single  factor 
in  surgery  of  the  abdomen  relates  to 
peritoneal  adhesions.  They  lead  to  a 
large  part  of  the  constipation  from 
which  the  public  is  suffering;  to  an 
extremely  important  part  of  the 
obscure  dyspepsias;  to  various  local 
areas  of  pain  and  tenderness,  and  fre- 
quently enough  to  acute  disasters. 
The  surgery  of  peritoneal  adhesions 
belongs  to  the  surgery  of  the  future 
for  the  reason  that  such  adhesions  are 
commonly  overlooked  by  diagnosti- 
cians at  the  present  time,  and  only  a 
trifling  percentage  of  cases  of  gastric 
and  bowel  disturbances  are  placed 
where  they  belong  in  cause  and  effect 
relationship  to  adhesions.  The  new 
work  of  filling  the  stomach  with  bis- 
muth solution  and  then  making  fluoro- 
scopic examination  to  determine  points 
of  interference  with  gastric  motility  is 
now  allowing  us  to  make  the  diagnosis 
of  gastric  adhesions  freely. 

In  post-mortem  work  we  find  peri- 
toneal adhesions  at  some  point  in 
pretty  much  every  abdominal  cavity, 
in  adults  at  least,  and  the  argument 
that  these  have  not  caused  trouble 
during  the  patient's  lifetime  includes 


1—3 


34 


ABDOMEN,    SURGERY   OF    (MORRIS). 


the  idea  that  the  patient  is  to  have 
made  the  diagnosis  himself,  and  to 
have  informed  his  physician  in  the 
ordinary  course  of  narration  of  his 
troubles.  In  this  article  the  subject 
of  peritoneal  adhesions  can  receive 
nothing  more  than  brief  treatment, 
but  it  may  be  disposed  of  in  a  general 
way  which  includes  most  of  the  prin- 
ciples. 

The  surgeon  has  to  consider  the 
matter  of  separating  peritoneal  adhe- 
sions when  they  are  found  to  give 
trouble,  and  to  prevent  their  recur- 
rence. He  has  to  take  steps  in  his 
operative  work  which  will  guard 
against  the  formation  of  adhesions 
resulting  from  his  work.  On  the 
other  hand,  he  has  to  resort  to  the  use 
of  peritoneal  adhesions  established 
for  his  own  purposes  in  many  parts 
of  abdominal  work.  In  cases  in 
which  we  wish  to  make  use  of  peri- 
toneal adhesions  it  is  important  to 
scarify  the  peritoneum  in  the  vicinity 
with  the  point  of  a  needle  in  order  to 
make  sure  of  the  free  exudation  of 
lymph  together  with  destruction  of 
part  of  the  endothelial  layer.  The 
desirability  of  this  scarification  is  ex- 
perienced in  laboratory  work  where 
one  is  working  with  animals,  and  it 
leads  to  the  feeling  that  sometimes  we 
do  not  obtain  adhesions  enough  for 
safety  in  some  kinds  of  bowel  work, 
unless  scarification  has  insured  their 
production. 

When  we  wish  to  prevent  the 
re-formation  of  adhesions  which  had 
formed  in  advance  of  operation,  many 
resources  are  of  more  or  less  value, 
but  the  author  has  chiefly  depended 
upon  two.  These  consist  in  the  use 
of  the  aristol  film,  and  the  Cargile 
membrane  made  of  the  sterilized 
peritoneum  of  the  ox.    Aristol  film  is 


obtained  by  sprinkling  aristol  freely 
over  the  oozing  surface  from  which 
adhesions  have  been  separated,  press- 
ing the  aristol  upon  these  tissues 
firmly  with  a  pad  of  gauze,  and  then 
leaving  the  area  exposed  to  the  air 
for  a  moment  until  the  lymph-coagu- 
lum  engages  most  of  the  aristol  in  its 
mesh.  This  presents  a  mechanical 
obstacle  to  the  re-formation  of  adhe- 
sions. The  author  has  found  aristol 
in  the  tissues  of  animals  after  ex- 
perimentation, several  months  after 
operation.  This  material  probably 
disappears  in  time  through  slow 
liquefaction  in  the  fat  of  cells  which 
are  undergoing  retrograde  metamor- 
phosis. 

To  prevent  the  re-formation  of  peri- 
toneal adhesions  by  using  Cargile 
membrane,  this  material  is  laid  upon 
oozing  surfaces  from  which  adhesions 
have  been  separated,  and  it  may  be 
caught  at  several  points  with  strands 
of  very  fine  catgut  in  case  it  does 
not  adhere  well  enough  naturally. 
Fingers  and  instruments  must  be 
very  dry  while  applying  this  animal 
membrane ;  otherwise,  it  has  a  tendency 
to  adhere  to  the  fingers  and  instru- 
ments, rather  than  to  the  tissues  of  the 
patient.  Cargile  membrane  is  best 
transferred  from  a  pad  of  dry  gauze  to 
the  incised  tissues.  Animal  membrane 
used  in  this  way  acts  like  the  aristol 
film  in  presenting  a  mechanical  obsta- 
cle to  readhesion,  but,  unlike  the  aristol 
film,  it  has  a  tendency  to  undergo 
very  rapid  absorption  in  the  peri- 
toneal cavity,  remaining  sufficiently 
long,  however,  as  a  rule,  to  serve  as 
a  conductor  for  new  endothelium 
beneath  its  protecting  surface.  Lubri- 
cating adhesion  areas  with  sterile  oil  at 
the  time  of  operation  is  favored  by 
some  surgeons,  on  the  ground  that  per- 


ABDOMEN,    SURGERY    OF    (MORRIS). 


35 


istalsis  keeps  oiled  tissues  moving  too 
freely  to  allow  of  adhesicnis. 

Adhesions  for  the  most  part  under- 
go absorption  by  lymphaties  under 
ordinary  physiologic  conditions,  but 
where  there  has  been  much  disturb- 
ance of  tissue,  infective  or  traumatic, 
the  connective  tissue  which  replaces 
the  reparative  lymph  may  remain 
permanently.  It  may  act  in  various 
ways':  by  inhibiting  peristalsis  of  the 
bowel  and  causing  constipation,  or 
exposing  the  patient  to  the  danger 
of  angulation  of  the  bowel  at  adherent 
points.  Adhesions  may  cause  local 
irritation  and  discomfort  only,  or  they 
ma}^  lead  to  complete  strangulation 
of  any  of  the  tubular  structures. 
They  may  become  pulled  out  into 
long  strands  which  ensnare  the  bowel, 
or  wdiich  roll  the  omentum  into 
abnormal  positions,  and  they  may 
prevent  the  normal  gliding  of  viscera, 
and  give  rise  to  distant  reflex  dis- 
turbances. 

In  separating  recently  formed  adhe- 
sions, it  is  best  to  separate  them  in  as 
limited  a  way  as  will  suffice  for  the 
completion  of  our  work.  The  reason 
for  this  is  because  recently  separated 
new  adhesions  are  prone  to  re-form 
imanediately  in  spite  of  all  our  efforts, 
and  they  may  re-form  in  such  a  way 
as  to  be  more  injurious  than  when 
gradually  arranged  according  to  na- 
ture's plans. 

To  avoid  the  danger  of  formation 
of  adhesions  which  were  not  present 
at  the  time  of  an  operation  we  avoid 
rough  handling  of  the  peritoneum, 
which  not  only  increases  operative 
shock,  but  which  stimulates  the  peri- 
toneum to  throw  out  an  undue 
amount  of  lymph.  The  danger  of  the 
formation  of  such  adhesions  following 
traumatism  produced  by  the  operator 


is  sometimes  greater  than  the  danger 
from  adhesions  which  form  under 
local  septic  conditions. 

When  in  the  course  of  operative 
work  it  becomes  necessary  to  with- 
draw loops  of  bowel,  omentum,  or 
other  intra-abdominal  structures,  it  is 
important  to  prevent  them  from  be- 
coming dry,  chilled  or  exposed  to  the 
vast  numbers  of  bacteria  constantly 
falling  upon  them  from  the  air,  and 
this  is  obviated  by  covering  exposed 
surfaces  with  a  thin  sheet  of  rubber 
dam  or  of  gutta-percha  tissue  while 
we  are  at  work.  Gauze  as  a  protect- 
ive agent  is  objectionable,  because  it 
injures  the  endothelial  surfaces  at 
once  unless  it  is  quite  wet  with  saline 
solution,  and  has  a  special  tendency 
to  cause  subsequent  adhesion  forma- 
tion. 

Some  peritoneums  do  not  form 
adhesions  of  consequence,  even  under 
marked  provocation,  while  in  other 
cases  they  appear  despite  all  precau- 
tions. Consequently  in  abdominal 
surgery  we  must  always  have  in  mind 
the  possibility  of  adhesion  formation 
which  may  nullify  our  best  efforts  in 
an  operative  way.  Traumatism  of 
the  peritoneum  is  particularly  to  be 
avoided  when  we  wish  to  sponge  out 
fluids  from  the  peritoneal  cavity,  and 
this  sponging  can  often  be  done  be- 
tween the  fingers  of  the  operator's 
two  hands.  He  places  his  hands 
about  the  field  which  is  to  be  sponged 
in  such  a  way  as  to  make  a  little  well 
down  to  the  fluid,  and  the  assistant, 
carrying  gauze  into  the  abdominal 
cavity,  brushes  the  gauze  repeatedly 
against  the  fingers  of  the  operator, 
rather  than  against  the  delicate  peri- 
toneum. 

The  two  points  at  w^hich  we  need 
to    open   the   peritoneal    cavity   most 


36 


ABDOMEN,    SURGERY   OF    (MORRIS). 


often  for  relief  of  adhesions  are  in  the 
bile-tract  region  and  in  the  cecal 
reg'ion.  The  incision  for  reaching 
adhesions  in  the  bile-tract  region  is 
commonly  made  along  the  free  border 
of  the  ribs  over  the  adhesion  area, 
and  in  the  cecal  region  the  ordinary 
incision  for  reaching  the  appendix 
suffices. 

INTESTINAL  SUTURES.— 
Operations  on  the  intestinal  tract, 
despite  their  number  and  variety,  can 
be  reduced  to  a  few  simple  steps  of 
technique  of  which  the  most  impor- 
tant element  is  the  application  of 
sutures  and  other  retentive  apparatus. 

In  excision  the  principal  stage  of 
the  operation  is  with  the  insertion  of 
sutures.  In  primary  anastomoses  the 
,apolication  of  the  suture  constitutes 
most  of  the  operation.  The  cutting, 
consisting  of  making  a  communicat- 
ing opening  after  the  suturing,  is 
partly  done.  A  general  outline  of 
suturing  and  its  substitute  procedures 
is  therefore  necessitated. 

To  secure  union  in  most  wounds  of 
the  bowel  a  continuous  suture  of  fine 
catgut  is  first  passed  through  both 
mucous  and  muscular  coats,  and  the 
peritoneum  is  closed  over  all  with 
a  continuous  Lembert  suture  of  fine 
silk. 

Silk  or  linen  thread  are  necessary 
for  all  sutures  of  the  bowel  which 
are  to  hold  more  than  a  few  hours, 
for  the  reason  that  catgut  is  digested 
very  quickly,  if  it  enters  the  secret- 
ing glands  of  the  bowel,  and  it  is 
commonly  taken  up  also  with  great 
rapidity  by  the  peritoneum.  This  two- 
plane  suture  known  as  the  Czerny- 
Lembert  is  the  evolution  of  years  of 
inte^inal  surgery,  and  is  so  firm  as 
to  prevent  any  possibility  of  leakage, 
but  the  apposition  of  the  two  peri- 


toneal surfaces  insures  peritoneal 
union  almost  immediately. 

In  most  cases  it  is  best  to  scarify 
the  peritoneum  with  the  point  of  a 
needle  wherever  peritoneal  adhesion 
is  desired.  This  scarification  with 
the  needle  insures  the  exudation  of  a 
large  amount  of  reparative  lymph. 
Any  narrowing  of  the  intestinal 
caliber  under  this  suture  is  for  the 
most  part  temporary,  as  expansion  of 
the  bowel  will  take  pla-ce  at  that  point 
later,  and  even  the  loss  of  a  third  of 
its  circumference  does  not  lead  to 
actual  stenosis. 

Any  operation  which  consists  in 
the  closure  of  a  wound  in  the  long 
axis  of  the  bowel  involves  in  general 
no  different  suturing.  This  applies 
also  to  certain  operations  for  pyloro- 
plasty and  gastroplasty  when  a  trans- 
verse incision  is  changed  into  a 
vertical  one  with  a  resulting  increase 
of  caliber.  Whenever  a  cut  surface 
of  intestine  does  not  enter  into  the 
restoration  of  continuity,  it  must  be 
closed  by  a  suture  in  the  same  way 
and  under  the  same  principle  as 
linear  wounds.  Sutures  of  this  type 
are  applied  to  the  cut  surface  of  the 
stomach  or  intestine  when  these  do 
not  enter  directly  into  anastomosis. 
In  pylorectomy  for  cancer  by  Bill- 
roth's  first  method  the  cut  stomach  is 
simply  sutured  down  to  a  point  which 
makes  the  caliber  the  same  as  the 
caliber  of  the  cut  duodenum.  A  cut 
end  of  intestine  may  also  be  closed 
by  Lembert  sutures,  for  the  principle 
remains  always  the  same. 

When  two  cut  surfaces  are  to  be 
directly  united  by  so-called  end-to- 
end  anastomosis  the  double  plane  of 
suture  is  applied  as  before,  but  the 
exigencies  here  are  such  that  it  is 
sometimes   advisable  to  Insert  some 


ABDOMEN,    SURGERY    OF    (MORRIS). 


37 


of  the  peritoneal  sutures  first.  Thus 
the  serous  sutures  are  phiced  for 
about  one-half  the  extent  of  the  open- 
ing" to  be  closed ;  then  the  deep  pene- 
trating layer  is  inserted  for  the  entire 
circumference,  and  finally  the  balance 
of  the  serous  sutures  are  inserted. 

This  plan  of  suturing  is  followed  in 
a  great  variety  of  procedures,  and  as 
a  rule  for  end-to-end  anastomoses  and 
implantations  and  secondary  suturing 
in  general.  In  primary  anastomoses 
the  principle  is  the  same,  some  of  the 
suturing  being  done  in  the  interest  of 
accurate  coaptation  before  the  anasto- 
motic opening  is  made.  Thus,  the  parts 
to  be  joined  having  been  placed  in  jux- 
taposition, with  the  fingers  or  with 
clamps,  the  two  portions  of  gut  are 
first  joined  by  a  number  of  serous 
sutures,  about  half  the  number  to  be 
required  eventually.  The  opening  is 
then  made  and  the  all-embracing  layer 
of  continuous  catgut  serves  to  unite 
the  edges  of  the  same,  after  which  the 
serous  suture  is  completed. 

To  prevent  small  masses  of  mucosa 
from  pouting  beyond  the  suture  line 
while  invaginating  the  mucosa  by  the 
ordinarj^  methods  of  suture,  the  writer 
passes  the  suture  from  the  mucosa  out- 
ward through  all  the  coats  of  the  in- 
testine, instead  of  from  without  in,  as 
is  usually  done.  V.  Schmieden  (Zen- 
tralbl.  f.   Chir.,  April  15,   1911). 

McGraw  Ligature. — A  loop  of 
bowel  is  brought  against  the  portion 
of  stomach  with  which  it  is  to  be  con- 
nected, and  the  two  structures  are 
fastened  together  with  a  continuous 
durable  Lembert  suture  for  a  distance 
of  two  and  one-half  inches.  The 
stomach  and  bowel  are  then  fastened 
together  with  a  McGraw  strand  of 
solid  rubber  introduced  with  a  large 
needle,  preferably  the  Hagedorn  full- 
curve    type.      The    needle    is    passed 


through  the  wall  of  the  stomach  to 
the  lumen,  and  then  brought  out 
again  at  a  point  two  inches  away. 
The  needle  traverses  the  wall  of  the 
intestine  in  tlie  same  way.  The 
rubber  strand  then  being  drawn  tight 
is  tied  in  such  a  wa}^  as  to  constrict 
the  included  parts  as  snugl}^  as  pos- 
sible. The  elastic-rubber  knot  is  still 
further  held  by  tying  it  with  a  strand 
of  silk  or  linen.  The  next  step  com- 
pleting the  operation  consists  in  ap- 
proximating the  portions  of  stomach 
and  bowel  which  were  left  free  after 
the  preliminary  suturing  was  done. 
The  McGraw  ligature  was  devised 
originally  for  gastroenterostomy,  but 
is  useful  as  well  for  enteroenteros- 
tomy. 

Murphy's  Button. — Wherever  great 
speed  in  operating  is  a  desideratum 
Murphy's  button  gives  an  advantage, 
and  if  it  were  not  for  the  fact  that 
buttons  are  sometimes  retained,  or 
that  they  sometimes  give  rise  to  com- 
plications per  sc,  a  vei*y  large  part  of 
our  intestinal  anastomosis  work  could 
be  done  with  the  aid  of  this  ingenious 
resource. 

Two-stage  Operations. — Some  of 
the  procedures  for  establishing  gas- 
trostomy, enterostomy  and  colostomy 
are  performed  in  two  stages,  the  delay 
being  for  the  purpose  of  allowing 
adhesions  to  form  about  the  incisions 
and  thereby  protect  the  peritoneal 
cavity.  Any  operation  whatever  in 
which  the  external  wound  is  not  com- 
pletely closed  may  become  a  two- 
stage  procedure  if  a  special  operation 
is  necessary  to  close  the  wound.  As 
a  rule,  however,  a  considerable  inter- 
val elapses  in  such  cases,  too  long  in 
fact  to  enable  us  to  regard  it  as  a 
single  operative  intervention.  AVhen 
Avounds  are  closed  outright  there  is  a 


38 


ABDOMEN,    SURGERY    OF    (MORRIS). 


possibility  that  they  may  at  once 
require  reopening  for  hemorrhage  or 
sepsis.  Hence,  despite  modern  asepsis 
which  has  enabled  us  to  operate  so 
extensively  in  one  stage,  the  abdom- 
inal operator  is  constantly  exposed  to 
the  possibility  of  operating  in  succes- 
sive stages. 

SURGICAL  DISEASES  OF  THE 
STOMACH.— We  shall  first  enumer- 
ate the  disorders  in  which  surgical 
procedures  are  necessary,  and  then  de- 
scribe under  a  special  heading  the  va- 
rious operations  resorted  to. 

Gastric  and  Duodenal  Ulcers. — 
These  require  a  variety  of  surgical  pro- 
cedures at  various  stages  of  their  de- 
velopment. Recent  or  older  ulcers 
may  cause  fatal  hematemesis,  per- 
forative peritonitis,  and  crippling  ad- 
hesions. From  their  location  near  the 
pylorus,  actual  or  healed  ulcers  may 
cause  pyloric  stenosis.  It  must  not 
be  forgotten,  however,  that  gastric 
and  duodenal  ulcer  is  a  malady 
largely  amenable  to  medical  treat- 
ment, some  forms  not  requiring  sur- 
gery at  all,  but  surgical  intervention 
is  indicated  just  as  soon  as  medical 
resources  lose  efficiency,  and  at  an 
earlier  period  than  is  customary  as 
yet.  The  better  diagnoses  made  by 
physicians  in  late  years,  and  the  ex- 
tremely satisfactory  surgery  of  the 
present  day  bring  the  question  of 
time  for  operation  to  a  point  which 
can  generally  be  agreed  upon  by 
expert  physicians  and  surgeons. 

Gastric  ulcers  are  frequently  multi- 
ple, and  unless  one  is  aware  of  this 
fact  he  may  overlook  others  while 
caring  for  the  first  one  which  appears 
in  the  course  of  an  operation.  An 
active  ulcer  of  the  stomach  may  be 
surrounded  by  latent  ulcers,  or  by 
scars  which  need  excision,  or  which 


call  for  gastroenterostomy  quite  as 
much  as  the  acute  condition. 

Perforating  ulcer  of  the  stomach  is 
the  one  most  often  calling  for  imme- 
diate operation,  while  the  chronic 
changes  of  the  stomach  due  to  scarring 
from  old  ulceration  allow  of  more  de- 
liberate action. 

The  so-called  bleeding  ulcer  with- 
out induration  or  tendency  to  per- 
foration, while  chiefly  medical,  some- 
times calls  for  surgical  relief,  and  it 
is  sometimes  very  difficult  to  find  the 
bleeding  point;  but,  if  the  stomach  is 
opened  at  a  point  not  far  from  the 
pylorus,  pressure  of  the  finger  upon 
various  folds  and  rugae  or  gentle 
wiping  with  a  small  gauze  pad  will 
excite  hemorrhage  anew.  The  ar- 
teries leading  to  this  area  may  be 
ligated  or  separated,  or,  if  the  site  is 
far  enough  away  from  the  pylorus  to 
avoid  the  danger  of  stenosis,  a  simple 
infolding  of  this  part  of  the  stomach 
wall  with  sutures  results  in  putting 
this  part  of  the  stomach  at  rest  out  of 
the  range  of  peristalsis,  with  a  ten- 
dency to  cure  of  the  ulcer. 

Even  a  chronic  ulcer  thrown  out  of 
the  range  of  peristalsis  by  infolding 
of  the  stomach  wall  may  sometimes 
go  on  to  cure,  but  in  the  latter  class 
of  cases  it  is  usually  best  to  excise 
and  to  perform  a  gastroenterostomy. 
If  the  pancreas  is  involved  in  an 
operation  for  ulcer  of  the  stomach, 
any  escape  of  pancreatic  secretion 
may  cause  local  necrosis  of  tissues. 
Where  the  pyloric  portion  of  the 
stomach  is  much  scarred  from  old 
ulceration,  or  engaged  in  active 
ulceration,  complete  excision  of  this 
part  of  the  stomach  followed  by  some 
form  of  intestinal  anastomosis  is 
called  for.  Ulcer  of  the  stomach  at  a 
distance  from  the  pylorus  causes  some- 


ABDOMEN,    SURGERY    OF    (MORRIS). 


39 


times  hour-glass  stomach  through 
contraction  of  its  scars,  and  the  opera- 
tion for  this  condition  is  referred  to 
elsewhere. 

Duodenal  nicer  is  the  lesion  met  in 
nearly  two-thirds  of  the  cases  person- 
ally seen.  Unless  an  ulcer  is  demon- 
strated or  hemorrhage  requires  it,  oper- 
ation is  not  advised.  Gastrojejunos- 
tomy is  done  for  duodenal  ulcer; 
Finney's  gastroduodenostomy  for  py- 
loric stricture.  Proximal  gastrojeju- 
nostomy or  the  whole  area  excised  in 
hour-glass  contraction.  For  calloused 
nicer  of  the  pyloric  end  partial  gas- 
trectomy is  performed;  the  upper  end 
of  the  duodenum  is  closed,  and  pos- 
terior gastrojejunostomy  is  performed 
independently.  Of  234  patients  oper- 
ated more  than  two  years  before,  189 
were  cured,  21  improved,  10  were  un- 
improved, while  14  died  from  various 
disorders.  Mayo  (Trans.  Amer.  Surg. 
Assoc,  p.  142,  1908). 

Of  205  cases  in  which  operation  for 
chronic  gastric  or  duodenal  ulcers  had 
been   performed  the   results   two  years 
after      operation      were      as      follows : 
Cured   148,   relieved  5,   doubtful  9,  not 
improved  12;  of  14  not  heard  from,  11 
could  be  considered  as  cured.     Deaths 
from    operation    2,     gastric    cancer    7, 
various    disorders    8.      The     following 
practical  points:     The   operative  treat- 
ment  of    stomach    disorders   should   be 
confined   exclusively   to    those    cases    in 
which    an    organic    lesion    is    present. 
If  one  makes  a  diagnostic  mistake,  and 
displays  upon  the  operating  table  a  per- 
fectly   healthy    stomach,    gastroenteros- 
tomy   should    not    be    performed.      In 
cases  of  acute  perforation,  the  perfora- 
tion should  be  closed  or  the  ulcer  ex- 
cised.     If    the    ulcer    is    prepyloric    or 
duodenal,   gastroenterostomy   should  be 
performed.    If  an  ulcer  is  situated  upon 
the     lesser     curvature,     it     should     be 
excised    to     forestall    the    development 
of    malignant    disease.     If    an    ulcer    is 
prepyloric,    pyloric,    or    duodenal,    gas- 
troenterostomy    should    be    performed. 
When    possible,    the    ulcer    should    be 
infolded,    since    hemorrhage    and    per- 


foration have  occurred  from  ulcers 
months  or  even  years  after  the  per- 
formance of  gastroenterostomy.  The 
most  satisfactory  method  of  gastro- 
enterostomy is  the  posterior,  no-loop 
operation,  with  an  almost  vertical  appli- 
cation of  the  bowel  to  the  stomach. 
Regurgitant  vomiting  occurs  as  a  re- 
sult of  the  loop  operation,  whether 
anterior  or  posterior.  It  is  almost  cer- 
tainly relieved  by  enteroanastomosis. 
In  slighter  cases  the  vomiting  of  bile 
may  be  relieved  by  lavage  continued 
for  some  weeks.  Moynihan  (Trans. 
Amer.  Surg.  Assoc,  p.  129,  1908). 

The  various  resources  for  giving 
gastric  and  pyloric  ulcer  a  chance  to 
heal  spontaneously  without  excision 
of  the  involved  area  would  often  be 
preferable,  were  it  not  for  the  fact 
that  cancerous  degeneration  of  the 
embryonic  blind  tubules  at  old  ulcer 
sites  is  a  frequent  occurrence. 

An  inexperienced  operator  had 
better  attempt  a  primary  anastomosis 
perhaps  and  risk  the  cancer.  Jejunos- 
tomy  purely  for  artificial  feeding  may 
be  done  to  prolong  life  in  cases  where 
the  patient  is  unable  to  withstand  a 
prolonged  operation.  AVhen  the  sur- 
geon is  first  summoned  after  perfora- 
tion has  occurred,  it  is  not  only  neces- 
sary to  expose  and  suture  the  opening 
and  cleanse  the  peritoneum,  but  it  is 
often  advisable  to  take  advantage  of 
the  opportunity  for  performing  a 
radical  operation,  if  one  is  actually 
indicated.  This  is  also  the  case  often- 
times in  emergency  intervention  for 
hemorrhage  from  an  ulcer,  and  in  pen- 
etrating wounds  of  the  stomach  it  is 
further  necessary  to  cleanse  the  peri- 
toneal cavity  in  the  vicinity. 

Carcinoma.— The  most  radical  pro- 
cedures are  indicated  only  when  there 
is  some  expectation  of  cure.  With 
early  recognition  and  improved  tech- 
nique    the     operative     mortality     is 


■40 


ABDOMEN,    SURGERY    OF    (MORRIS). 


slowly  diminishing-,  and  operative 
procedures  for  comfort  of  the  patient, 
rather  than  for  cure  within  the  three- 
year  limit,  are  increasing-  in  propor- 
tion. A  preliminary  laparotomy  is 
often  required  to  make  a  diagnosis  of 
operability  in  cancer.  It  is  often 
advisable  to  add  a  gastrotomy,  as 
otherwise  early  malignant  disease  has 
been  overlooked. 

The  only  operation  for  radical  cure 
is  partial  gastrectomy  with  extirpa- 
tion of  neighboring  lymph-nodes. 
Since  patients  with  well-recognized 
cancer  of  the  stomach  seldom  live 
beyond  a  year  and  suffer  greatly, 
palliative  operations  are  indicated  in 
theory,  but  it  must  be  remembered 
that  the  mortality  is  rather  high  in 
such  intervention.  The  resulting 
prolongation  of  life  is  also  so  slight 
'that  in  ordinary  cases  the  risk  would 
hardly  be  worth  while  were  it  not  for 
the  considerable  mitigation  of  suffer- 
ing. When  a  palliative  operation  is 
undertaken,  one  with  a  minimum  of 
intervention  is  indicated.  Jejunos- 
tomy  is  therefore  indicated  on  theory 
for  artificial  alimentation  and  com- 
plete rest  of  the  stomach.  In  certain 
cases  a  gastroenterostomy  may  be 
preferable. 

The  surgeon  demands  too  much  when 
he  requests  the  practitioner  to  turn 
over  cases  of  gastric  cancer  to  him 
early,  since  diagnosis  cannot  be  made 
sufficiently  early.  It  "were  better  if  he 
were  asked  to  turn  over  to  him  all  cases 
of  pyloric  obstruction,  without  waiting 
for  chemical  analyses,  which  at  best  are 
uncertain,  or  for  the  effects  of  medi- 
cines, none  of  which  relieve  mechanical 
obstruction.  Mayo  (Jour.  Amer.  Med. 
.  Assoc,  Aug.  15,  1908). 

Congenital   Stenosis   of   Pylorus. — 

Patients  with  this  affection,  even  when 
severe,  have  been  known  to  recover 


under  medical  treatment,  while  opera- 
tion for  radical  cure  has  a  high 
mortality,  excepting  at  the  hands  of 
experts.  Einhorn  has  recently  devised 
an  apparatus  for  dilating  the  con- 
stricted pylorus.  If  medical  measures 
fail,  gastroenterostomy  is  indicated 
early. 

Hour-glass  Stomach, — This  condi- 
tion is  considered  by  some  under  the 
results  of  gastric  ulcer,  its  usual 
causation.  When  it  is  discovered  by 
exploratory  laparotomy,  or,  better,  with 
the  fluoroscope,  gastroplasty  or  gastro- 
gastrostomy  may  be  indicated,  the 
former  for  enlarging  the  diameter  of 
the  constricted  portion,  and  the  latter 
for  establishing  a  new  communication 
between  the  stomach  pouches  when  the 
first-named  intervention  is  impracti- 
cable. Since  some  operators  perform 
a  secondary  gastroenterostomy  in  such 
cases  to  avert  the  necessity  for  a  pos- 
sible second  operation,  it  becomes  a 
question  whether  a  primary  anastomo- 
sis is  not  the  indication  of  choice.  The 
latter  in  any  case  may  be  made  with 
one  or  both  stomach  pouches,  accord- 
ing to  circumstances. 

Non-obstructive  or  Atonic  Dilata- 
tion.— Atonic  dilatation  of  the  stom- 
ach or  gastric  myasthenia,  like 
pylorospasm  and  relaxation  of  the 
pylorus,  is  only  a  symptom  of  some- 
thing else  which  needs  to  be  worked 
out  before  we  consider  any  operative 
work,  but  when  the  patient  is  losing 
ground  in  spite  of  other  treatment, 
and  we  have  pyloric  obstruction  due 
to  kinking,  a  gastrojejunostomy  or 
Finney's  operation  will  make  the 
work  of  the  physician  easier.  Fin- 
ney's operation  is  preferable  in  cases 
in  which  the  gastric  motility  is  not 
much  impaired.  Gastric  adhesions 
involving    the     stomach    lessen    the 


ABDOMEN,   SURGERY   OF    (MORRIS)." 


41 


movements  of  the  nnisciilnris  of  the 
stomach,  disturb  circulation,  and  pro- 
duce disturl)ances  which  predispose 
to  ulceration,  and  a  simple  separa- 
tion of  these  adhesions  in  some  cases 
of  chronic  ulcer  of  the  stomach 
or  pylorospasm  or  relaxed  pylorus 
obviates  need  of  other  treatment. 

The  operation  of  gastroplication, 
however,  is  usually  performed  for 
non-obstructive  or  atonic  dilatation, 
with  or  without  a  secondary  gastro- 
enterostomy; but  there  are  very 
many  cases  of  atonic  dilatation  which 
do  not  properly  belong  to  surgery  at 
all,  and  w^e  must  look  for  these  con- 
ditions as  reflex  from  some  peripheral 
irritation,  or  some  central  nervous 
derangement.  Atonic  dilatation  maj^ 
result  from  exhaustion  of  the  mus- 
cularis  due  to  persistent  attempts  for 
years  at  overcoming  partial  obstruction 
at  the  pylorus,  due  to  the  presence  of 
adhesions  or  ulcer  scars.  It  may  be 
due  to  the  influence  of  distant  periph- 
eral irritation,  such  as  loose  kidney  or 
eye-strain,  or  to  fibroid  degeneration 
of  the  appendix. 

All  these  possible  factors  must  be 
very  carefully  excluded  one  by  one, 
and  all  three  are  at  the  present  day 
generally  overlooked  by  diagnosti- 
cians. Atonic  dilatation  occurring 
with  certain  psychoses,  while  belong- 
ing in  the  medical  class,  may  never- 
theless sometimes  warrant  surgical 
intervention. 

Gastroptosis.  —  The  operation  of 
gastropexy  or  omentoplication  for 
shortening  the  suspensory  (gastro- 
hepatic)  ligaments  of  the  stomach  is 
indicated  in  this  condition,  if  the 
gastroptosis  occurs  singly,  but  it  is 
apt  to  be  associated  with  panptosis, 
due  to  relaxation  of  peritoneal  sup- 
ports  of  intra-abdominal   organs ;    so 


that  at  the  same  time  we  usually 
need  to  shorten  the  suspensory  liga- 
ment of  the  liver,  repair  a  diastasis 
of  the  rectus  muscles,  and  perhaps  fix 
loose  kidneys  in  place.  This  severe 
operation  makes  it  advisable  to  ac- 
complish all  that  is  possible  with 
external  supports  before  resorting  to 
operative  procedures.  Alost  of  the  pa- 
tients with  visceral  ptoses  are  neuras- 
thenics, and  surgery  is  of  temporary 
avail  only, — to  be  avoided  if  possible. 

Foreign  Bodies. — Gastrotomy  for 
the  removal  of  foreign  bodies  is  occa- 
sionally indicated,  and  does  not  differ 
from  ordinary  exploratory  gastrot- 
omy, excepting  that  the  incision  may 
be  made  ver}'  small  in  some  cases, 
and  just  large  enough  to  allow  the 
entrance  of  forceps,  which  may  be 
guided  to  the  object  through  the  aid 
of  the  fluoroscopic  screen.  This 
latter  resource  may  also  be  used  for 
reaching  small  objects  in  any  part  of 
the  intestinal  tract. 

Case  in  which  103  nails,  3  screws,  1 
brass  chain,  1  safety  pin,  and  1  sewing 
needle  were  removed  from  the  stomach. 
The  patient  recovered,  but  five  weeks 
later  pains  in  the  abdomen  developed, 
particularly  in  the  cecal  region,  which 
necessitated  a  reopening  of  the  ab- 
dominal cavity.  No  more  foreign 
bodies  were  found,  but  some  adhesions 
were  broken  up.  After  that  the  pa- 
tient remained  free  from  pain,  so  that 
evidently  the  renewed  pains  were  occa- 
sioned by  the  formation  of  adhesions 
in  the  abdominal  cavity.  Borchardt 
(Berl.  klin.  WocK,  Feb.  21,  1910). 

Stricture  of  the  •  Esophagus. — Gas- 
trostomy is  required  for  some  cases 
of  stricture  of  the  esophagus,  to 
furnish  access  from  two  directions 
for  dilatation  purposes. 

TYPICAL  OPERATIONS  UPON 
THE  STOMACH.— Gastroplication. 
— This   operation,  which  is  intended 


42 


ABDOMEN,    SURGERY   OF    (MORRIS). 


to  reduce  the  size  of  the  stomach  by 
infolding-  its  anterior  wall,  has  been 
done  successfully  for  simple  non- 
obstructive dilatation,  as  well  as  for 
cases  of  pyloric  obstruction  due  to 
the  presence  of  bile-tract  adhesions  or 
ulcer  scars.  In  several  cases  in  which 
gastroplication  seemed  to  be  indi- 
cated because  of  dilatation  secondary 
to  the  presence  of  adhesions,  a  simple 
separation  of  such  adhesions,  together 
with  gastric  lavage  and  massage  subse- 
quently, has  allowed  the  stomach  to  re- 
gain its  normal  dimensions. 

The  principle  of  the  operation 
involves  the  introduction  of  sutures 
placed  within  the  seromuscular  tissue. 
The  more  numerous  and  the  longer 
the  sutures,  the  greater  the  reduction 
in  the  capacity  of  the  organ.  The 
interrupted  sutures  are  inserted  at 
the  lesser  curvature,  and  passed  in 
and  out  at  intervals  of  one  inch  apart, 
until  the  anterior  wall  has  been 
traversed  without  tying  any  sutures. 
They  should  be  parallel  in  their 
course ;  the  end  sutures  must  not  be 
placed  so  as  to  be  in  danger  of  con- 
stricting the  lumina  of  the  esophageal 
or  pyloric  orifices. 

The  sutures  should  be  tied  only 
when  all  have  been  placed  in  a  row 
ready  for  knotting.  If  one  suture 
were  to  be  knotted  in  advance  of,  i.e., 
before,  the  introduction  of  the  next 
one,  it  would  run  the  operator  along 
in  an  undesirable  plane,  for  mechani- 
cal reasons  evident  while  one  is 
operating.  The  anterior  wall  will 
be  puckered,  creased  or  reefed  ac- 
cording to  the  technique  used,  with 
resulting  restoration  of  the  natural 
capacity  of  the  stomach.  The  sutures 
may  be  inserted  in  series  of  super- 
imposed planes  when  the  dilatation 
is  excessive. 


After  gastroplication  a  cross-sec- 
tion of  the  organ  shows  a  series  of 
plaits  if  one  plane  of  sutures  is  used; 
while,  if  several  planes  are  super- 
posed, a  sort  of  diaphragm  projects 
across  the  cavity.  These  formations 
tend  to  undergo  some  atrophy. 
Although  the  normal  size  of  the 
organ  is  restored,  the  shape  is  not, 
and  the  tendency  of  the  posterior 
wall  to  pouch  must  sometimes  be 
offset  by  a  posterior  gastroenteros- 
tomy. It  has  even  been  counselled  to 
perform  the  latter  as  a  matter  of 
routine. 

A  form  of  gastroplication  has  also 
been  performed  for  gastric  ulcer.  The 
reef  of  the  stomach  wall  which  is  the 
seat  of  the  lesion  is  thus  placed  in 
relative  rest,  and  under  appropriate 
medical  measures  the  ulcer  may  dis- 
appear during  the  atrophy.  Two 
suture  points  usually  suffice.  Natu- 
rally the  operation  is  best  suited  to 
ulcer  of  the  anterior  wall. 

Gastric  Omentoplication. — Gastric 
omentoplication  may  be  mentioned  in 
this  connection.  This  operation  con- 
sists in  taking  a  tuck  in  the  suspen- 
sory ligaments  of  the  stomach,  and  is 
indicated  in  gastroptosis.  These  por- 
tions of  the  lesser  omentum  known 
respectively  as  the  gastrohepatic  and 
gastrosplenic  ligaments  are  sutured 
in  three  superposed  planes  with 
mattress  sutures,  the  deepest  being 
inserted  for  a  very  short  distance, 
one-half  inch  to  one  inch  near  the 
pylorus.  The  next  plane  projects 
well  beyond  the  confines  of  the  first, 
while  the  third  corresponds  to  the 
amplitude  of  the  tuck  to  be  made. 
The  sutures  are  then  tied  in  the  order 
of  insertion.  It  must  be  borne  in 
mind  that  the  aim  of  omentoplica- 
tion   is    to    secure    elevation    without 


ABDOMEN,   SURGERY   OF    (MORRIS). 


43 


compromising-    the    mobility    of    the 
stomacli. 

Gastrotomy. — Incision  of  tlie  stom- 
ach is  indicated  primarily  for  explora- 
tion of  the  stomach,  and  at  the  same 
time  when  required  for  the  lemoval 
of  foreign  bodies,  tumors,  etc.,  check- 
ing hemorrhage,  and  dilating-  stric- 
tures at  either  orifice.  It  is  always 
desirable  after  the  laparotomy  incision 
to  examine  the  stomach  thoroughly 
from  without  before  incising  its  wall. 
The  technique  for  incising  the  stom- 
ach is  practically  the  same  in  different 
operations,  although  the  site  and  ex- 
tent may  var}^  with  the  condition  to 
be  treated.  The  usual  incision  is 
made  in  the  long  diameter  as  far  as 
possible  from  large  blood-vessels,  and 
is  not  less  than  three  or  more  than 
five  inches  long.  It  is  advisable  to 
wash  out  the  stomach  before  opera- 
tion, but  when  this  for  any  reason  has 
not  been  done  the  organ  must  be 
evacuated  by  sponging  gently  with 
gauze  or  flushing  with  a  siphon. 
Before  incision  the  stomach  must 
have  been  walled  off  from  the  peri- 
toneal cavity  with  gauze.  After  the 
purpose  of  the  operation  has  been  ful- 
filled, the  gastric  incision  is  closed 
with  one  or  more  planes  of  con- 
tinuous silk  or  linen  sutures  of  the 
Lembert  type. 
,  When  gastric  ulcer  is  present  some 
additions  to  the  technique  may  be 
required.  When  the  operation  has 
been  undertaken  for  hemorrhage 
from  the  ulcer,  the  latter  must,  if 
possible,  be  excised,  and  if  an  ulcer 
is  found  it  is  always  best  excised 
irrespective  of  the  question  of  hemor- 
rhage. It  may,  however,  be  impracti- 
cable to  excise,  from  the  position  of 
the  ulcer,  or.  because  of  multiple 
ulcers    or    bleeding    points,    or    the 


source  of  the  hemorrhage  may  be 
ol)scure.  Under  such  circumstances 
hemostatic  procedures  may  be  un- 
available, and  may  even  aggravate 
the  state  of  affairs.  The  only  resource 
in  such  cases  is  to  perform  gastro- 
jejunostomy. Whenever  an  ulcer  can 
be  excised,  the  wound  is  closed  first 
with  catgut  sutures,  and  a  Lembert 
silk  or  linen  serous  suture  must  be 
superposed. 

When  the  ulcer  is  seated  on  the 
posterior  wall  with  implication  of  the 
serous  coat,  it  can  hardly  be  dealt 
with  through  the  anterior  incision, 
and  therefore  an  incision  must  be 
made  through  the  transverse  meso- 
colon, and  the  posterior  wall  of  the 
stomach  brought  into  view.  When 
the  pylorus  is  the  seat  of  the  ulcer, 
simple  excision  will  be  inadvisable 
because  of  subsequent  stenosis,  and' 
pyloroplasty  will  be  indicated.  When 
there  is,  besides,  any  evidence  of  esoph- 
ageal stricture,  great  care  should  be 
taken  to  perform  gastrostomy  by  a  typ- 
ical method,  unless  there  is  a  possibil- 
ity that  the  obstruction  can  be  relieved 
and  the  treatment  completed  from 
above.  It  would  be  impracticable  to 
turn  an  ordinary  gastrotomy  incision 
into  a  gastrostomy^  fistula. 

Pyloroplasty  (Heinecke  -  Mikulicz 
Operation). — This  operation  consists 
in  restoring  the  original  caliber  of  the 
pylorus  when  it  is  the  seat  of  a  simple 
stricture,  or  when  suture  following 
excision  of  an  ulcer  would  result  in 
pyloric  stenosis.  As  cicatricial  stric- 
ture of  this  orifice  is  due  usually  to 
the  healing  of  ulcers,  the  operation  is 
practically  associated  with  this  condi- 
tion. Only  a  single  procedure  known 
as  the  Heinecke-Mikulicz  operation  is 
current  in  the  narrower  sense  of  the 
word,   as  other  operations   to  which 


44 


ABDOMEN,   SURGERY   OF    (MORRIS). 


the  name  is  given  are  in  part  gastro- 
duodenostomies. 

The  technique  is  as  follows :  The 
stomach  having  been  exposed  by  a 
median  incision,  the  pylorus  is  drawn 
out,  walled  off  from  the  peritoneal 
cavity,  and  incised.  The  presence  of 
adhesions  renders  this  stage  difficult 
and  sometimes  furnishes  a  contrain- 
dication. The  incision  may  be  made 
after  an  assistant  has  approximated 
the  stomach  and  duodenum,  each  at 
a  point  some  three  inches  beyond  the 
stricture.  The  incision  while  made 
in  the  long  axis  of  the  pyloric  end, 
extending  from  duodenum  to  stom- 
ach, is  really  made  from  following 
the  pyloric  curve,  of  a  horseshoe 
shape.  Any  redundant  tissue  is  ex- 
cised. If  a  fresh  ulcer  is  present  most 
authors  prefer  to  do  a  gastroduo- 
denostomy.  In  order  now  to  enlarge 
the  pyloric  lumen,  forceps  applied  to 
the  middle  of  each  lip  of  the  wound 
are  made  to  pull  it  into  a  straight 
transverse  incision.  In  this  position 
it  is  sutured  in  two  planes  including 
the  peritoneal  layer,  unusual  care 
being  required  because  the  incision  is 
not  sutured  in  its  original  plane. 

Despite  the  recommendations  of 
Mikulicz  and  other  eminent  surgeons, 
the  operation  has  many  drawbacks. 
Adhesions  are  likely  to  result,  and 
whether  from  this  or  other  causes  the 
stenosis  may  reappear.  The  indica- 
tions therefore  are,  as  a  rule,  better 
carried  out  by  performing  some  form 
of  gastroduodenostomy  or  pylorec- 
tomy. 

Pyloroplasty  by  Finney's  (Gould's) 
Method  and  Gastroduodenostomy. — 
In  both  of  these  procedures  an  anas-, 
tomosis  is  made  between  the  stomach 
and  duodenum,  but  the  objects  are 
entirely    unlike,    being    in    Finney's 


operation  the  widening  of  a  stenosed 
pyloric  orifice,  Avhile  in  the  latter  the 
pylorus  is  excluded  outright  by  a 
short  circuit.  Gastroduodenostomy 
does  not  differ  essentially  from  gas- 
troenterostomy in  general  save  that 
the  duodenum  mmst  be  mobilized 
beforehand.  As  that  step  is  also 
required  in  Finney's  pyloroplasty,  the 
latter  alone  needs  a  detailed  descrip- 
tion. 

The  operative  success  will  be  due 
to  the  mobility  of  the  duodenum, 
which  may  be  and  usually  is  more  or 
less  immobilized  by  secondary  adhe- 
sions, and  to  such  extent  sometimes 
as  to  appear  inoperable.  Aside  from 
adhesions  the  anatomic  relations  may 
be  such  as  to  require  considerable 
operative  manipulation  to  make  the 
parts  accessible,  sometimes  division  of 
gastric  ligaments.  Traction  sutures 
may  then  be  inserted  outside  of  the 
area  to  be  incised  for  the  purpose  of 
steadying  and  tightening  the  tissue, 
but  here  it  is  better  to  use  clamps,  as 
in  Gould's  modified  operation,  which 
brings  pyloroplasty  in  the  same  class 
as  other  anastomoses.  The  clamps 
grasp  the  duodenum  and  stomach  in 
the  long  diameter — not  in  the  trans- 
verse diameter,  which  would  be  the 
case  in  an  exclusion  of  short-circuit 
anastomosis — with  one  clamp  secur- 
ing the  duodenum  and  the  other 
the  stomach  just  above  the  greater 
curvature ;  the  two  are  brought  side 
by  side  and  the  two  portions  of 
intestine  united  by  continuous  sero- 
muscular sutures.  A  U-shaped  inci- 
sion is  now  made,  the  bend  of 
which  corresponds  to  the  pylorus. 
Redundant  mucous  membrane  is 
clipped  off;  the  resulting  diaphragm 
or  tongue  is  overcast  with  a  second 
row    of    continuous    sutures,    simple 


ABDOMEN,    SURGERY    OF    (MORRIS). 


45 


communication  now  being  established 
between  the  duodenum  and  stomach 
at  the  natural  orifice.  An  elliptic 
space  remains  to  be  closed  with  two 
planes  of  sutures,  one  all-embracing 
and  the  other  serous  and  muscular. 

Gastrostomy. — Hacker's  OpcratioJi. 
— This  procedure  is  rather  a  small 
gastrotomy  left  unsutured  than  a 
true  gastrostomy,  in  the  modern 
sense  of  the  term.  It  is  recommended 
chiefly  in  emergencies.  The  stomach 
having  been  exposed  and  temporar}^ 
traction  sutures  passed  through  its 
wall  to  steady  the  organ,  two  planes 
of  permanent  sutures  are  inserted  on 
either  edge  of  the  wound.  The  first 
plane  passes  through  the  abdominal 
wall  only,  including  the  peritoneum; 
the  second,  placed  just  within  the 
others,  includes  in  its  grasp  the  walls 
of  the  stomach,  but  without  entering 
the  cavity.  The  sutures  are  then  tied 
and  cut  close,  so  that  the  stomach  is 
fixed  to  the  abdominal  wall.  Addi- 
tional smaller  sutures  are  left  in  place, 
and  the  wound  packed  with  gauze. 

At  a  subsequent  period,  usually 
the  following  day  or  the  second  day, 
the  wall  of  the  stomach  is  opened 
with  a  knife,  the  wound  being  one- 
half  inch  long  or  just  the  size  to 
contain  a  tube  which  should  fit 
closel3^  The  traction  sutures  should 
now  be  withdrawn.  The  abdominal 
incision  for  this  operation  should  be 
three  inches  long  and  vertical  in 
direction,  slightly  over  an  inch  to  the 
left  of  the  linea  alba,  and  beginning 
about  one  inch  beneath  the  costal 
arch.  AVhen  the  rectus  muscle  is 
exposed  the  anterior  fascia  is  divided 
with  the  scissorSj  but  the  belly  of  the 
muscle  is  separated  bluntly.  The 
posterior  layer  of  the  sheath  is  again 
divided    with    the    scissors,    exposing 


the  peritoneum.  This  is  opened  only 
sufficiently  to  admit  the  finger,  but 
subsequently  prolonged  with  blunt 
scissors,  and  the  peritoneum  and 
muscle  sutured  with  catgut. 

Franck's  operation  is  a  so-called 
valve  operation,  in  which  the  portion 
of  stomach  wall  to  be  incised  is 
passed  out  of  a  relativel}^  large  orifice 
under  a  bridge  of  skin,  and  finally  out 
of  a  smaller  incision,  in  which  local- 
ity it  is  incised. 

The  layer  incision  is  known  as 
Fenger's  and  runs  parallel  to  the 
costal  arch  and  about  one  inch  below 
the  latter,  starting  to  the  left  of  the 
ensiform  cartilage  and  not  exceeding 
two  inches  in  length.  When  the 
parietal  peritoneum  is  divided  it  is 
sutured  to  the  muscles  of  the  abdom- 
inal wall.  AMth  two  fingers  in  this 
opening  the  anterior  wall  of  the 
stomach  is  drawn  out  and  the  apex 
of  the  resulting  cone  transfixed  with 
a  traction  suture^,  while  a  running 
silk  suture  unites  the  base  of  the 
cone  to  the  edges  of  the  wound,  all 
the  tissues  being  embraced  except  the 
skin  and  the  gastric  mucosa. 

The  lesser  incision  is  parallel  to  the 
first  and  seated  an  inch  above  the 
margin  of  the  costal  arch.  Its  length 
should  not  exceed  one  inch.  The 
tissues  between  the  two  incisions  are 
then  detached  from  the  subcutaneous 
structures,  when  with  the  aid  of  the 
traction  suture  the  apex  of  the  cone 
is  drawn  under  the  bridge  of  skin  and 
out  of  the  lesser  opening,  to  the  edges 
of  which  it  is  sutured.  The  major 
orifice  is  then  closed  and  the  apex  of 
the  stomach,  cone  opened,  a  tube 
being  placed  within  the  canal.  The 
Fenger  incision  may  be  replaced  by 
a  vertical  one,  as  advised  by  Robson 
and  others. 


46 


ABDOMEN,    SURGERY    OF    (MORRIS). 


WitseVs  Operation.  —  The  canal, 
which  acts  as  a  valve,  passes  ob- 
liquely through  the  wall  of  the  stom- 
ach. The  anterior  surface  of  the  latter 
is  exposed  in  the  usual  manner  and 
sutured  to  the  wound;  an  opening  is 
then  made  in  the  central  portion, 
toward  the  greater  curvature.  Into 
this  a  soft  catheter  is  passed;  the 
portion  outside  the  stomach  is  laid 
flat  against  the  latter,  and  directed 
downward  and  outward. 

Sutures  are  now  passed  through 
the  seromuscular  coats  of  the  stomach 
over  the  tube  and  through  the  oppo- 
site side  so  that  when  tightened  the 
tube  is  covered  by  a  fold  of  stomach 
wall.  The  first  suture  point  is  seated 
one  inch  from  the  opening  in  the 
stomach  and  the  entire  length  of  the 
canal  should  be  about  an  mch  and  a 
half.  The  abdominal  wound  is  closed 
down  on  the  free  end  of  the  tube, 
which  is  left  projecting. 

Kader's  Operation. — The  tube  enters 
the  stomach  directly  instead  of  ob- 
liquely, and  the  canal  is  formed  by 
producing  an  artificial  thickening  of 
the  stomach  with  certain  planes  of 
suturing.  Thus  with  the  tube  in  situ, 
two  folds  of  stomach  wall  are  formed 
by  inserting  sutures  twice  through 
the  wall — one  to  each  side  of  the 
tube.  These  are  tightened  and  cut 
close,  and  similar  sutures  are  next 
inserted  just  outside  the  first.  Each 
plane  comprises  four  sutures.  The 
canal  thus  produced  is  about  half  an 
inch  long  and  has  a  good  valvular 
action. 

A  similar  canal  may  be  produced 
by  several  planes  of  purse-string 
sutures,  as  recommended  by  the  late 
Dr.  Senn. 

Author's  Operation. — The  author 
constructs  a  fistula  lined  with  epithe- 


lium;, by  utilizing  long  skin  flaps.  At 
the  left  costal  border,  over  the  chosen 
stomach  region,  make  an  incision  five 
inches  long  through  the  skin  and  sub- 
cutaneous tissues  directly  cephalad 
from  the  costal  border.  Make  a  simi- 
lar incision  on  either  side  of  the  first 
incision,  giving  two  ribbons  of  skin 
each  one  inch  in  width.  A  transverse 
incision  at  the  cephalad  end  of  the  par- 
allel incisions  frees  the  ends  of  the 
skin  ribbons.  The  skin  ribbons  are 
next  freed  throughout  their  length, 
but  remain  attached  at  the  costal  bor~ 
der.  The  epithelial  surfaces  of  the 
skin  ribbons  are  placed  in  apposition 
and  a  running  suture  of  catgut  unites 
their  margins.  This  transforms  the 
ribbons  into  a  tube  of  skin.  The  stonv 
ach  is  exposed  and  opened.  The  free 
end  of  skin  tube  is  sutured  with  silk  to 
the  mucosa  of  the  stomach.  A  rubber 
tube  is  passed  through  the  skin  tube. 
One  end  of  the  rubber  tube  is  to  re- 
main in  the  lumen  of  the  stomach  un- 
til repair  of  the  wound  is  complete. 
The  other  end  of  the  rubber  tube 
emerges  from  the  skin  tube  on  the  ab- 
dominal wall,  and  serves  for  introduc- 
ing nourishment.  When  the  skin  tube 
with  its  contained  rubber  tube  follows 
the  stomach  into  place,  the  remaining 
structures  to  be  sutured  have  fallen  to- 
gether in  such  a  way  that  the  character 
of  final  suturing  is  apparent,  and  needs 
no  description.  After  repair  of  the 
wound  is  sufficient,  at  the  end  of  a  few 
days,  the  rubber  tube  is  removed.  This 
leaves  a  fistula  lined  with  epithelium 
extending  between  abdominal  skin  and 
stomach  mucosa.  The  stomach  has 
drawn  the  skin  tube  into  position  at 
such  an  angle  that  atmospheric  pres- 
sure keeps  the  skin  tube  closed,  except- 
ing at  times  when  food  is  to  be  intro- 
duced. 


ABDOMEN,    SURGERY   QF    (MORRIS). 


47 


The  writer  makes  an  incision  in  tlic 
abdominal  wall  in  the  median  line, 
from  the  tip  of  the  xiphoid  cartilage 
downward  3  or  4  inches.  The  left 
hand  is  then  introduced  into  the  wound 
and  the  abdominal  wall  on  the  left  side 
grasped  between  the  middle  finger  and 
thumb.  In  this  way  the  left  rectus 
muscle  is  located.  With  a  long  teno- 
tome an  opening  is  made  through  the 
substance  of  the  left  rectus  from  the 
wound  surface  to  emerge  on  the  skin 
surface  a  few  centimeters  within  the 
outer  border  of  the  rectus.  This  open- 
ing is  widened  by  cutting  upward  and 
downward  and  dividing  the  rectus  into 
two  equal  layers,  an  anterior  and  a 
posterior.  The  size  of  this  passageway 
should  correspond  to  that  of  the  por- 
tion of  the  stom.ach  which  is  to  be 
drawn  through.  This  portion  of  the 
stomach  is  then  drawn  through  with  a 
suitable  forceps  and  its  base  sewed  to 
the  posterior  edge  of  the  median  end 
of  the  passageway  with  3  catgut  su- 
tures. The  opposite  surface  of  the  base 
is  then  sutured  to  the  peritoneum  and 
rectus  on  the  opposite  side  of  the  median 
wound.  The  deep  edges  of  the  upper 
and  lower  portions  of  the  median 
wound  are  then  brought  together  by 
sutures.  The  end  of  the  projecting 
portion  of  the  stomach  is  now  con- 
ducted through  the  tunnel  made  for  it 
in  the  rectus  muscle  and  skin,  and  its 
apex  is  fastened  to  the  skin  edges  of 
the  small  lateral  external  opening.  The 
large  median  wound  is  then  closed  over 
the  projecting  portion  of  stomach  by 
two  layers  of  sutures,  one  for  the  fascia 
and  the  other  for  the  skin.  Finally,  the 
emerging  end  of  the  stomach  is  opened 
and  its  edges  sutured  to  the  skin.  This 
portion  provides  a  strong,  permanent 
sphincter  for  the  gastrostomy  opening 
and  makes  it  continent.  Lafaro  (Deut. 
Zeit.  f.  Chir.,  Bd.  cviii,  S.  307,  1911; 
Amer.  Jour.   Med.   Sci.,  April,   1911). 

Gastrorrhaphy. — The  operation 
comprises  working  beyond  an  emer- 
genc}^  suture  of  the  stomach  wall  for 
traumatisms,  the  latter  including 
perforation  from  gastric  ulcer.     But 


since  gastrorrhaphy  is  involved  in 
suturing  a  gastrotomy  wound  there 
is  little  to  be  said  under  a  special 
heading  beyond  the  statement  that 
some  modifications  arise  from  the 
nature  of  the  injury.  While  the 
operation  is  readily  performed  after 
incised  and  lacerated  wounds,  but 
few  victims  of  such  injuries  recover 
— practically  none  after  gunshot 
wounds.  The  technique  of  closing 
stomach  wounds  is  described  with 
gastrotomy. 

Report  of  218  cases  from  the  opera- 
tive clinic  at  Rochester  from  January  1, 
1905,  to  April  1,  1909.  Eight  were  from 
the  duodenum,  and  of  these  all  were 
simple  ulcers.  The  remaining  210  were 
from  the  stomach.  Of  these,  47  were 
ulcers  without  suspicion  of  carcinoma, 
2  were  sarcomas,  2  adenomas,  and  1  a 
diverticulum.  Of  the  remaining  158 
in  the  stomach,  5  were  ulcers  with 
enough  microscopic  appearance  to  place 
them  in  the  doubtful  class  as  possible 
transition  cases.  Of  the  remaining  153 
cases,  which  were  undoubted  carcinoma, 
109,  or  71  per  cent.,  presented  sufficient 
microscopic  evidences  of  previous  ulcer 
to  warrant  grouping  them  as-  carcinoma 
developing  on  previous  ulcer.  Whereas, 
theoretically  at  least,  it  has  been  con- 
sidered probable  for  many  years  that 
there  was  an  immediate  relationship 
between  gastric  ulcer  and  carcinoma, 
the  profession  has  never  before  been 
treated  to  a  paper  so  convincing,  both 
because  of  its  source  and  because  of  its 
individual  excellence.  Generally  speak- 
ing, the  writers  show  that  a  little  more 
than  two-thirds  of  a  very  long  series 
of  carcinomas  undoubtedly  took  their 
origin  in  pre-existing  ulcers.  Wilson 
and  MacCarty  (Amer.  Jour.  Med.  Sci., 
Dec,  1909). 

Report  of  12  successive  perforations 
of  the  stomach  or  duodenum  with  11 
recoveries,  in  which  great  importance 
was  attached  to  rapid  operation;  no 
irrigation;  multiple  drainage  (one  tube 
to  the  site  of  perforation,  a  second  and 
third    in    the    right    and    left    lumbar 


48 


ABDOMEN,    SURGERY   OF    (MORRIS). 


region,  and  a  fourth  in  the  suprapubic 
region  if  fluid  exists  in  the  pelvis)  ; 
elevation  of  the  patient's  body;  early- 
feeding  by  the  mouth  and  continuous 
saline  irrigation  by  rectum  imme- 
diately after  operation.  Carwardine 
(Lancet,  vol.  i,  p.  239,  1910). 

According  to  the  author's  experience, 
the  prognosis  in  perforating  gastric  and 
duodenal  ulcers  is  fairly  good  if  opera- 
tion be  resorted  to  during  the  first 
twelve  hours  v^rhen  the  pulse  rate  does 
not  exceed  100,  while  it  is  quite  un- 
favorable if  the  pulse  is  120  or  over. 
As  regards  treatment,  suture  of  the 
perforation  after  excision  of  the  mar- 
gins of  the  ulcer  or  of  the  entire 
ulcerated  area  and  very  gentle  removal 
of  the  exudate  from  the  abdominal 
cavity  are  indicated  in  suitable  cases. 
This  should  be  followed  by  gastro- 
enterostomy only  in  patients  operated 
on  during  the  first  twelve  hours  in 
whom  the  general  condition  is  com- 
paratively good  and  when  the  history 
reveals  undoubted  symptoms  of  pyloric 
stenosis  or  where  the  pylorus  is  found 
to  be  stenosed.  Of  the  ulcers  observed 
94  were  localized,  T(i  to  the  stomach 
and  18  to  the  duodenum.  No  better 
illustration  of  the  importance  of  early 
operation  is  afforded  than  the  fact  that 
two-thirds  of  the  cases  operated  upon 
during  the  first  twelve  hours  recovered. 
G.  Petren  (Beitrag.  z.  klin.  Chir.,  Bd. 
Ixxii,  Hft.  2,  1911). 

In  the  treatment  of  severe  gastric 
hemorrhage  Rovsing's  method,  which 
the  writer  has  employed  since  two 
years,  has  proved  very  serviceable.  It 
consists  of  the  introduction  of  a  dia- 
phanoscope, an  especially  devised  instru- 
ment, through  an  incision  in  the  stom- 
ach, thus  permitting  of  direct  inspection 
of  its  walls.  This  method  permits  of 
the  detection  of  very  small  ulcerations, 
no  larger  than  a  pea,  while  any  bleeding 
vessel  can  usually  be  seen.  The  hemor- 
rhage is  arrested  by  applying  a  ligature, 
taking  in  the  entire  thickness  of  the 
stomach  wall,  and  this  area  buried  by 
one  or  two  purse-string  sutures.  After 
removal  of  the  diaphanoscope  the  gas- 
tric wound  is  sutured.    In  4  or  5  cases 


of  severe  hemorrhage  this  procedure 
caused  arrest  of  the  bleeding.  L.  Kraft 
(Archiv  f.  klin.  Chir.,  Bd.  xciii,  Hft.  3, 
1911). 

Gastroplasty. — Gastroplasty  is  a 
procedure  which  is  indicated  only  in 
hour-glass  stomach,  and  differs  but 
slightly  from  pyloroplasty,  the  con- 
striction of  the  organ  taking  the  place 
of  the  pylorus.  As  in  Finney's 
pyloroplasty,  the  two  portions  of  the 
stomach  are  first  brought  together  by 
sutures  or  clamps  and  a  horseshoe 
incision  made  around  the  suture  line 
at  a  distance  of  one-fourth  inch.  The 
inner  or  posterior  edge  of  the  wound 
having  been  stitched  by  a  continuous 
suture,  the  outer  or  anterior  edge  is 
similarly  treated.  The  communica- 
tion between  the  two  halves  of  the 
stomach  is  thereby  greatly  amplified. 
Reinforcing  sutures  will  probably  be 
required  for  the  anterior  sutures. 

Gastroplasty  may  also  be  per- 
formed along  the  lines  laid  down  for 
the  Heinecke-Mikulicz  pyloroplasty, 
in  which  a  transverse  incision  is 
changed  to  a  vertical  one. 

The  value  of  the  operation  is  in 
question. 

Gastrogastrostomy. — Like  gastro- 
plasty the  operation  is  indicated  only 
in  hour-glass  stomach.  It  consists  of 
a  simple  anastomosis  between  the 
halves  of  the  stomach,  which  then 
possesses  two  distinct  communicating 
passages.  The  two  stomach  pouches 
are  sutured  together  with  a  continu- 
ous Lembert  silk  suture  along  one 
side.  The  two  pouches  are  next 
incised,  and  the  cut  surfaces  joined 
-as  in  gastroenterostomy,  and  final 
suturing  completes  the  apposition  of 
the  pouches. 

Partial  Gastrectomy. — Partial  gas- 
trectomy, the  name  of  which  is  self- 


ABDOMEN,    SURGERY   OF    (MORRIS). 


49 


explanatory,  is  undertaken  chiefly  for 
cancer  of  the  p}-lorus,  and  to  a  certain 
extent  for  cancer  of  the  stomach 
proper,  gastric  ulcer,  and  hour-glass 
stomach.  AX'hen  performed  for  benign 
ulceration  the  cases  selected  are  those 
near  the  pylorus  when  the  lesion  is 
unusuall}'  large,  indurated  or  multi- 
ple. AMien  done  for  hour-glass  stom- 
ach the  constriction  between  the 
storiiach  pouches  is  the  seat  of  an 
ulcer,  and  the  excision  can  be  com- 
bined with  gastrogastrostomy. 

Technically  the  mere  excision  of  a 
bleeding  ulcer  anywhere  in  the 
stomach  is  a  partial  gastrectomy,  but 
in  the  tA^pical  operation  the  pylorus 
must  be  sacrificed,  and  therefore  the 
continuity  of  the  digestive  tube  must 
be  restored  by  some  form  of  gastro- 
enterostomy, either  gastroduodenos- 
tomy  by  end-to-end  anastomosis,  a 
gastroduodenostomy  by  implanting 
the  duodenum  in  the  stomach  wall, 
or  an  ordinary  gastroenterostomy. 
Partial  gastrectomy  has  been  divided 
into  a  typical  and  a  cylindrical 
method,  but  the  former,  which  relates 
only  to  incision  of  ulcer  areas  in  the 
stomach  proper,  is  sufficiently  com- 
prehended under  gastrotomy.  Cylin- 
drical gastrotomy  is  also  termed 
pylorectomy,  since  the  pylorus  is 
always  excised  completely,  alone  or 
with  more  or  less  of  the  entire  con- 
tinuous gastric  wall.  Over  a  third 
of  the  organ  may  thus  be  sacrificed. 

BillrotJi's  Operation. — The  original 
method  practised  by  this  surgeon  was 
to  excise  the  p3'lorus  and  the  neces- 
sary portion  of  the  stomach  wall,  and 
to  suture  the  cut  end  of  the  stomach 
until  it  reached  the  size  of  the  duo- 
denum. The  two  cut  ends  were  then 
joined  by  end-to-end  anastomosis. 
At  a  later  period  the  same  surgeon 


preferred  to  close  up  both  cut  ends 
and  perform  a  posterior  gastrojeju- 
nostomy. 

Billroth  prefaced  his  pylorotomy 
by  ligating  the  vessels  of  the  greater 
and  lesser  curvatures,  and  next  tied 
ofT  the  peritoneal  attachments  (gas- 
trohepatic  and  gastrocolic  ligaments). 
This  mobilization  enables  the  p^dorus 
to  be  drawn  out  of  the  external  inci- 
sion. Clamps  are  then  applied  to 
either  side  of  the  p3dorus,  two  pairs 
each  to  duodenum  and  stomach,  at  a 
distance  of  an  inch  from  the  diseased 
area.  Fingers  or  clamps  may  be  used 
on  the  proximal  sides.  The  stomach 
and  then  the  duodenum  are  divided 
between  the  clamps.  The  divided 
end  of  the  stomach  is  sutured,  after 
complete  hemostasis  is  secured  with 
a  running  suture  of  chromicized  gut, 
passed  through-and-through  on  each 
side  in  order  to  secure  some  inversion. 
The  suture  is  carried  from  above 
downward  to  such  a  distance  that  the 
unstitched  portion  corresponds  in 
size  to  the  cut  surface  of  the  duo- 
denum. A  second  through-and- 
through  suture  plane  is  added  and 
serves  to  further  invert  the  wound 
edges. 

The  duodenum  is  not  divided  until 
the  stomach  has  been  sutured.  The 
two  divided  ends  are  now  partly 
joined  by  a  continuous  Lemberf 
suture,  leaving  room  to  apply  an  in- 
folding through-and-through  suture 
of  chromicized  catgut  within  the 
plane  of  the  outside  suture,  which 
latter  is  then  completed. 

Kochcr's  Operation. — In  this  method 
the  cut  end  of  the  stomach  is  com- 
pletely closed  while  the  cut  end  of 
the  duodenum  is  implanted  into  the 
posterior  wall  of  the  stomach.  The 
pylorectomy    itself    does    not    dififer 


50 


ABDOMEN,    SURGERY    OF    (MORRIS). 


essentially  from  that  of  Billroth. 
The  divided  end  of  the  stomach  is 
completely  closed  by  two  planes  of 
sutures,  an  inner  continuous  through- 
and-through  suture  of  chromicized 
gut,  and  a  Lembert  suture  outside  of 
it.  The  essential  part  of  the  opera- 
tion consists  in  the  gastroduodenos- 
tomy  by  which  the  cut  edge  of  the 
duodenum  is  implanted  about  two 
inches  behind  the  closed  wound  of 
the  stomach.  The  duodenum  held  in 
position  with  fingers  is  first  made 
fast  to  the  stomach  by  a  running 
Lembert  suture  inserted  at  the  point 
of  contact  with  the  stomach  and 
occupying  one-half  of  the  gut  just 
back  of  the  cut  edge.  The  stomach 
is  then  incised  just  beyond  this  suture 
line  in  such  manner  that  the  two 
edges  may  be  exactly  approximated. 
The  anastomosis  is  now  made  with  a 
continuous  interior  suture  of  chromi- 
cized gut,  and  the  original  outside 
suture  is  completed.  The  interior 
anastomosis  suture  is  inserted  by  the 
through-and-through  method,  and 
traverses  all  the  coats  of  the  intestine. 

Hartmann's  operation  differs  from 
the  preceding  in  that  it  includes  ex- 
tirpation of  the  lymph-nodes  which 
are  seated  within  the  gastrohepatic 
ligament.  It  is  therefore  only  appli- 
cable to  cancer  of  the  pylorus  in  a 
more  or  less  advanced  but  still  oper- 
able stage.  The  operation  proper  and 
its  termination  by  gastroduodenos- 
tomy  or  gastroenterostomy  is  not 
different  materially  from  the  pre- 
ceding. 

Maya's  operation  is  also  a  radical 
procedure,  and  involves  not  only 
extirpation  of  lymphatics  draining 
the  pyloric  area,  but  an  unusual 
degree  of  removal  of  stomach,  includ- 
ing   all   the    lesser    curvature.     The 


stomach  is  closed  entirely,  and  con- 
tinuity restored  by  any  of  the  methods 
in  vogue. 

The  mortality  if  lowered  (1)  by  pro- 
tecting the  operative  field  against  the 
escape  of  gastric  contents  during  the 
operation ;  (2)  by  using  a  combination 
of  morphine,  hyoscine,  and  chloroform 
for  narcosis,  thus  reducing  the  likeli- 
hood of  pneumonia;  (3)  by  limiting  the 
operation  to  patients  in  whom  the 
hemoglobin  percentage  is  relatively 
high.  In  such  cases  the  stomach  may 
be  resected  some  centimeters  beyond 
the  disease.  Czerny  (Annales  Intern. 
de  Chir.  Gastro-Intes.,  vol.  ii,  p.  61, 
1908). 

Review  of  266  partial  gastrectomies 
involving  the  pyloric  end  of  the  stom- 
ach performed  in  the  Saint  Mary's 
Hospital,  Rochester,  between  April  21, 
1897,  and  Jan.  27,  1910.  There  were  34 
deaths  from  the  operation,  a  mortality 
of  12.4  per  cent.  Some  of  the  patients 
are  still  living  eight  years  after  the 
operation.  The  writer  does  not  believe 
the  pessimism  as  regards  this  operation 
to  be  justified  by  the  facts.  He  calls 
attention  to  two  important  indications 
for  operation  in  gastric  cancer :  1. 
Food  remnants  found  repeatedly  in  the 
stomach  after  twelve  hours  should, 
when  taken  in  connection  with  the 
clinical  history,  call  for  a  surgical  con- 
sultation, which  in  a  large  majority  of 
cases  will  lead  to  an  exploratory  opera- 
tion. 2.  The  finding  of  a  movable 
tumor  in  the  pyloric  end  of  the  stomach 
cannot  be  overestimated  as  to  its  sur- 
gical significance.  Gastric  cancer  by 
itself  does  not  give,  he  is  convinced, 
characteristic  symptoms  during  the  cur- 
able stage.  But  if  it  is  situated  in  the 
pyloric  end  of  the  stomach  mechanical 
conditions  are  early  induced  which 
afford  most  valuable  information.  An 
effort  should  always  be  made  to  remove 
the  lymphatic  area,  whether  diseased  or 
not.  It  must  be  removed  before  the 
lymphatics  are  infected.  Prophylaxis 
of  gastric  cancer  can  be  aided  by  the 
excision  of  calloused  gastric  ulcers, 
which  are  its  origin  in  70  per  cent. 
A  typical  resection  necessitates  the  re^ 


ABDOMEN,    SURGERY   OF    (MORRIS). 


51 


moral  of  all  that  part  of  the  stomach 
lying  to  the  right  of  a  line  dropped 
vcrticall}^  from  the  cardiac  orifice, 
though  in  some  cases  more  of  the  fun- 
dus must  be  removed  on  account  of  the 
direct  extension  of  the  disease.  As  a 
general  rule,  it  will  be  most  convenient 
to  make  the  separation  of  the  superior 
border  of  the  stomach  first,  beginning 
the  operation  by  (a)  ligation  of  the 
superior  pyloric  vessel,  (b)  the  gastric, 
(c)  the  felt  gastroepiploic,  (d)  the 
gastroduodenal  vessels.  As  each  vessel 
is  secured,  the  glandular  separation  is 
effected.  In  doing  the  anterior  gastro- 
jejunostomy he  usually  follows  the 
method  of  Hartmann,  i.e.,  the  two-row 
suture  method  with  slight  modifications. 
Generally  speaking,  the  Kocher  method 
of  joining  the  jejunum  to  the  stomach 
is  not  so  satisfactory  as  the  Billroth 
No.  2  method,  i.e.,  closing  both  the  end 
of  the  duodenum  and  the  stomach  and 
making  an  independent  gastrojejunos- 
tomy. When  the  patient  is  in  good 
condition  the  operation  has  an  operative 
mortality  of  under  S  per  cent.  In  ad- 
vanced cases,  the  resection  is  worth  the 
risk,  considering  the  short  lease  of  life 
of  patients  left  without  it.  W.  J.  Mayo 
(Jour.  Amer.  Med.  Assoc,  May  14, 
1910). 

Complete  Gastrectomy. — This  oper- 
ation, including-  subtotal  gastrectomy, 
is  now  practicable  as  a  method,  and 
has  radically  cured  perhaps  a  very 
few  individuals  of  cancer,  but  is 
seldom  attempted,  the  operative  mor- 
tality being  very  great  and  cases  suit- 
able for  such  intervention  seldom 
recognized  in  time.  Removal  of  the 
stomach  is  not  a  difficult  operation  at 
all,  but  search  for  and  removal  of 
lymph-nodes  must  be  very  thorough. 
The  removal  is  followed  by  an  end- 
to-end  anastomosis  made  between  the 
duodenum  and  esophagus,  or  the  cut 
end  of  the  former  ma}"  be  closed  and 
the  esophagus  implanted  into  the 
jejunum.  The  author  has  found  it 
much  easier  to  do  the  work  if  a  small 


part  of  the  cardiac  end  of  the  stomach 

is  allowed  to  remain. 

In  76  cases  of  cancer  of  the  stomach 
during  the  last  ten  years,  the  growth 
was  inoperable  in  21;  in  11  cases  a 
radical  operation  was  undertaken. 
Of  these,  7  were  completely  cured;  in 
the  other  4  the  operation  was  at- 
tempted as  a  last  resort  without  much 
hope  of  permanent  success.  In  the 
cured  patients  nine-tenths  of  the 
stomach  had  been  removed;  the  age 
of  the  patients  ranged  from  38  to 
75.  Direct  anastomosis  between  the 
stomach  and  duodenum  was  possible 
in  all  but  1  of  these  cases;  2  of  this 
group  of  7  cured  patients  have  suc- 
cumbed since  to  an  intercurrent 
afifection.  The  others  are  in  good 
health  to  date,  the  postoperative  life 
being  over  five  years  in  one  instance. 
Boeckel  (Bull,  de  I'Acad.  de  med.,  Oct. 
4,  1910). 

Case  of  complete  gastrectomy  in  a 
man  aged  43.  The  whole  organ  was 
removed.  The  cut  end  of  the  esophagus 
was  stitthed  to  the  side  of  a  loop  of 
jejunum.  The  patient  made  a  good 
recovery  from  the  operation.  During 
the  three  years  and  eight  months  that 
he  lived  after  the  operation  he  was 
under  constant  observation.  He  was 
perfectly  well  up  to  the  early  part  of 
the  j^ear  1910,  v.'hen  he  began  to  show 
the  evidences  of  a  profound  anemia. 
He  was  strikingly  pale  and  breathless, 
and  he  lost  weight.  Under  treatment, 
however,  he  improved,  and  in  May, 
1910,  his  color  had  returned  and  he  was 
able  to  ride  and  drive  and  attend  to 
matters  on  the  farm.  In  August,  1910, 
he  began  to  fail  again ;  he  became 
easily  tired,  though  he  still  tried  to 
carry  out  the  greater  part  of  his  work. 
His  appetite  remained  good  and  he  had 
no  indigestion.  In  October,  the  signs 
of  anemia  reappeared,  he  grew  much 
weaker,  and  had  to  cease  work.  He 
began  again  to  lose  weight,  his  appetite 
vanished,  .and  he  vomited  occasionally. 
There  were  no  abnormal  signs  of  any 
kind  in  the  chest  or  abdomen  through- 
out the  illness.  Soon  after  Christmas, 
1910,  he  had  to  take  to  his  bed,  and 
he    died   on   the   last   day   of   January, 


52 


ABDOMEN,    SURGERY   OF    (MORRIS). 


1911.  He  had  gained  38  pounds  after 
the  operation,  and  he  held  the  gain  for 
nearly  three  years.  His  appetite  was 
good,  he  experienced  the  sensation  of 
hunger,  and  he  was  able  to  eat  ordinary 
foods.  Moynihan  (Lancet,  Aug.  12, 
1911). 

SURGICAL  DISEASES  OF  THE 
PERITONEUM.— Septic  Peritonitis, 

— This  condition  being  in  the  great 
majority  of  cases  secondary  to  some 
suppurative  process  either  within  or 
without  the  peritoneal  cavity,  the 
treatment  cannot  be  considered  inde- 
pendently of  that  of  the  primary 
condition,  which  consists  fundament- 
ally of  incision  and  drainage  of  or 
removal  of  the  pyogenic  focus.  The 
conditions  likely  to  give  rise  to  peri- 
tonitis are  separately  mentioned.  If 
the  focus  is  outside  the  peritoneal 
cavity,  the  latter  need  not  necessarily 
be  opened,  because  the  peritoneum 
rapidly  guards  itself  by  hyperleuco- 
cytosis  after  a  focus  of  infection  is 
cared  for.  If  the  focus  is  in  the  peri- 
toneal cavity,  it  may  or  may  not  be 
advisable  to  treat  the  peritoneum 
actively.  If  the  peritonitis  comes 
from  an  intestinal  perforation  an 
enterorrhaphy  may  be  required,  but 
it  is  often  safer  to  make  temporary 
drainage,  and  fistulse  following  have 
a  tendency  to  close  spontaneously. 
Other  cases  may  require  excision,  as 
when  a  portion  of  the  gut  is  gangren- 
ous. In  many  cases,  however,  posture 
and  drainage  alone  are  indicated,  and 
any  unnecessary  handling  of  the  peri- 
toneum is  to  be  deprecated.  Only 
when  drainage  cannot  offer  a  pros- 
pect of  self-limitation  of  the  process 
is  a  thorough  cleansing  of  the  peri- 
toneum indicated,  and  this  is  best 
accomplished  by  flushing  with  hot 
saline  solution  through  short  incision, 
and  the  glass  tube. 


Results  obtained  in  100  well-marked 
cases  of  diffuse  septic  peritonitis  re- 
sulting from  inflammation  of  the  vermi- 
form appendix.  The  cases  were  treated 
by  the  author  and  by  George  R.  Fow- 
ler. Sixty-seven  of  the  cases  recov- 
ered. Of  the  33  deaths,  17  occurred 
within  twenty-four  hours  of  operation. 
The  salient  points  in  the  treatment  of 
these  cases  were  :  A  small  incision  and 
the  avoidance  of  eventration;  thorough 
cleansing  of  the  primary  focus  of  in- 
fection and  removal  of  the  appendix. 
Evacuation  and  cleansing  of  all  acces- 
sory abscess  cavities  and  the  pelvis  be- 
fore washing  out  the  peritoneal  cavity. 
A  rapid  systematic  flushing  of  the  peri- 
toneal cavity  with  sodium  peroxide 
solution  followed  by  hot  saline.  The 
continuance  of  the  saline  flushing  until 
the  sutures  are  placed,  and  for  the  most 
part  tied.  The  provision  of  proper 
drainage  of  septic  fluid  into  the  pelvis, 
of  a  large  glass  tube  containing  a  capil- 
lary drainage  strip  emerging  through 
the  lower  angle  of  the  wound  or, 
in  females,  by  a  large-caliber  rubber 
tube  filled  with  wicking  passed  through 
a  posterior  colpotomy  incision.  The 
drainage  of  accessory  abscess  cavities 
with  gauze  or  wicking.  The  elevation 
of  the  head  of  the  bed  to  accelerate  the 
drainage  of  septic  fluid  into  the  pelvis, 
where  it  can  be  removed  throvigh  the 
glass  tube,  or,  in  case  of  vaginal  drain- 
age, find  a  ready  exit.  R.  S.  Fowler 
(Med.  News,  May  28,  1904). 

Murphy's  treatment  consists  in  mak- 
ing a  small  opening 'in  the  abdomen, 
doing  such  operation  at  the  point  of 
origin  of  the  peritonitis  as  is  required, 
the  introduction  of  a  large  drainage- 
tube  into  the  pelvis,  placing  the  patient 
in  a  sitting  posture  of  35  to  40  degrees, 
and  the  administration  of  a  salt  solu- 
tion every  two  hours  per  rectum.  An 
important  feature  of  the  treatment  is 
to  avoid  handling  the  intestines  or 
peritoneum  more  than  is  absolutely 
necessary.  It  is  remarkable  how 
much  salt  solution  is  absorbed  and 
how  it  increases  elimination  by  the 
kidneys.  As  much  as  18  pints  of 
water  may  be  administered  by  the 
rectum  in  twenty-four  hours   and  all 


ABDOMEN,   SURGERY   OF    (MORRIS). 


53 


retained;  this  is  only  accomplished, 
however,  by  elevating  the  douche  bag 
but  eighteen  inches  above  the  bed 
and  allowing  the  solution  to  flow 
into  the  bowel  very  slowly.  The 
rectal  tube  can  be  kept  in  twenty-four 
to  forty-eight  hours.  Water  should 
also  be  administered  by  the  mouth. 
Gibbon  (New  York  Med.  Jour.,  April 
7,  1906). 

The  mortality  of  general  peritonitis 
of  but  a  few  years  ago  (65  per  cent. 
in  1069  collected  cases  between  1888  to 
1904,  55  per  cent,  in  400  cases  between 
1900  to  1904,  SO  per  cent,  in  the  Mayo 
clinic)  is  remarkable  in  its  contrast 
with  that  of  J.  B.' Murphy  in  December, 
1906,  i.e.,  38  consecutive  cases  with  but 
a  single  death,  and  that  from  pneu- 
monia on  the  sixth  day. 

It  was  Murphy's  protest  against  gen- 
eral irrigation  of  the  abdomen,  show- 
ing that  the  higher  mortality  rested 
with  those  who  used  it,  that  first  at- 
tracted the  attention  of  surgeons.  His 
first  paper  dealt  with  5  cases  (includ- 
ing 1  typhoid  case)  without  a  death, 
was  followed  in  October,  1906,  with  28 
cases  with  1  death,  and  up  to  his  last 
paper  includes  48  consecutive  cases 
with  only  2  deaths.  These  astounding 
results  have  been  recently  also  con- 
firmed in  England.  Moynihan  states 
that,  in  his  opinion,  and  as  a  result  of  a 
fairly  large  experience  of  the  method, 
"there  are  few  therapevttic  measures 
equal  to  it,"  and  Cawardine  considers 
it  "the  most  valuable  suggestion  of 
recent  times." 

The  principles  laid  down  by  Murphy 
are :  1.  Operate  early.  2.  Operate 
quickly.  Murphy  gives  ten  minutes  as 
the  average  time  in  which  to  close  the 
gastric  or  duodenal  opening,  or  to  re- 
move the  offending  appendix  or  tubes. 

3.  The  anesthetic  must  always  be  ether, 
if  the  patient  can  stand  it;  if  not,  then 
a  local  anesthetic.  Stiles's  work  has 
shown  how  dangerous  chloroform  is  in 
acute  suppurative  conditions,  in  the 
production    and    retention    of    acetone. 

4.  It  is  a  fatal  mistake  to  mop,  wash, 
or  handle  the  intestine.  The  peri- 
toneum is  essentially  an  absorbing  sur- 
face; carmine  granules  injected  into  its 


cavity  are  rapidly  absorbed,  especially 
in  its  upper  half,  and  conveyed  by  the 
lymph-stream  to  the  general  circulation. 
Organisms  similarly  do  harm  by  the 
rapid  absorption  of  their  toxins  in  a 
similar  manner.  Lymph,  like  any  other 
granulating  surface,  is  protective,  and 
tends  to  prevent  this  absorption.  All 
undue  manipulation  of  such  lymph- 
covered  surfaces,  or  lymph  removal  by 
sponging,  washing,  or  mopping,  will  in- 
crease, therefore,  the  danger  of  septic 
absorption.      5.  The      Fowler      position 


Peritonitis  treated  by  the  Murphy  method. 

and  a  suprapubic  drain.  The  object  of 
the  Fowler  position  is  to  allow  the  dis- 
charges to  gravitate  toward  the  pelvis, 
and  away  from  the  danger  zone  of  the 
diaphragm.  The  patient,  as  soon  as  he 
has  recovered  from  the  anesthetic,  is 
placed  in  the  sitting  posture,  so  that  the 
abdominal  cavity  is  vertical  in  position, 
and  drainage  is  instituted  by  placing  a 
large  drain  in  the  pelvis  through  a  stab 
wound  above  the  pubis.  This  drainage- 
tube  is  three-fourths  to  one  inch  in 
diameter,  about  eight  inches  long,  glass, 
and  goes  down  tj  the  pouch  of  Doug- 
las in  the  female,  and  the  rectovesical 
in  the  male.  In  this  position  the  tube 
is  almost  horizontal ;  and  if  it  is  filled 


S4 


ABDOMEN,   SURGERY   OF    (MORRIS). 


with  fluid,  each  excursion  of  the  dia- 
phragm will  pump  a  small  quantity  of 
it  out  into  the  dressings.  The  hole  is 
now  at  the  most  dependent  part  of  the 
abdominal  cavity.  6.  Proctoclysis  or 
the  absorption  of  large  quantities  of 
saline  by  the  rectum  for  the  first  two 
days  after  operation.  As  soon  as 
possible  after  the  operation,  a  tube 
having  numerous  holes  in  it  and  one- 
half  inch  in  diameter  is  inserted  into 
the  rectum  for  about  two  to  three 
inches.  This  is  connected  by  means 
of  a  rubber  tube  of  the  same  diameter 
with  a  container  suspended  from  four 
to  tweh^e  inches  above  the  plane  of 
the  patient's  couch,  and  the  whole  is 
filled  with  warm  saline.  By  means 
of  this  head  of  water  (it  need  onU'- 
be  four  to  six  inches  in  height,  as  a 
rule)  saline  gradually  trickles  into 
the  rectum  at  about  the  rate  of  three- 
quarters  to  one  pint  an  hour.  The 
temperature  of  the  saline  is  kept  at 
100°  F.  and  sho  ild  never  reach  106° 
F.,  or  it  will  not  be  retained.  The 
object  is  not  for  the  saline  to  act  as 
an  enema,  but  to  be  given  so  slowly 
that  it  is  absorbed  as  fast  as  it 
flows  in.  If  the  patient  feels  a  desire 
to  defecate,  it  means  that  the  rectum 
is  becoming  so  distended  that  the  head 
of  water  is  too  great,  and  that  it  must 
be  decreased.  Should  the  desire  be- 
come overwhelming,  then  the  saline  is 
shut  off  for  a  time  until  the  desire 
disappears.  R.  E.  Kelly  (Liverpool 
Medico-Chir.  Jour.,  July,   1909). 

Out  of  a  series  of  167  cases  of  dif- 
fuse septic  peritonitis  from  appendicitis 
operated  on  by  the  writer  at  varying 
intervals  following  perforation  up  to 
January,  1909,  there  were  but  15  pa- 
tients operated  on  within  twenty-four 
hours  of  the  onset.  Patients  with  dif- 
fuse septic  peritonitis  from  appendicitis 
operated  on  within  twenty-four  hours 
of  the  onset  of  the  disease,  i.e.,  before 
the  peritoneum  is  infiltrated,  recover, 
providing  the  primary  focus  is  removed 
quickly  without  damaging  the  absorb- 
ing power  of  the  peritoneum,  irrespect- 
ive of  feeding  or  enemas,  providing 
the  absorbing  power  of  the  peritoneum 
is  properly  used.  Fowler  (Surg., 
Gynec,  and  Obstet,  Nov.,  1909). 


The  writer  treated  some  15  cases  of 
diffuse  peritonitis  with  intravenous  in- 
jections of  adrenalin.  In  every  in- 
stance, there  was  a  marked  improve- 
ment in  the  pulse  fo.  a  short  time;  but 
this  disappeared  in  a  few  minutes,  and 
in  one  or  two  hours  the  effect  had 
passed  away.  In  a  few  patients,  the 
increased  pressure  in  the  vessels  con- 
tinued, and  these  patients  recovered. 
The  symptoms,  however,  were  indis- 
tinguishable from  those  which  follow 
an  injection  of  normal  saline  solution. 
These  results  coincide  exactly  with  the 
experiments  upon  animals.  Adrenalin 
is  well  known  to  excite  an  increased 
tension  in  the  blood-vessels,  which  lasts 
only  a  few  minutes.  This  is  equally 
true  whether  the  animal  is  in  a  normal 
condition  or  has  an  acute  peritonitis. 
The  improvement  in  the  arterial  ten- 
sion lasts  somewhat  longer  when  the 
adrenalin  is  given  with  a  saline  trans- 
fusion than  it  does  when  the  adrenalin 
is  given  alone.  Heineke  (Zentralbl.  f. 
Chir.,  S.  72,  Beilage,  1909). 

Tuberculous  Peritonitis. — In  theory 
the  local  focus  of  disease  which  has 
caused  an  extension  of  the  process  to 
the  peritoneum  should  be  excised, 
whether  this  is  in  the  intestine,  Fallo- 
pian tube,  appendix,  or  other  remov- 
able tissues.  But  this  is  not  always 
practicable,  and,  furthermore,  patients 
often  recover  under  simple  laparot- 
omy and  drainag-e.  The  author  in  a 
series  of  experiments  with  animals 
some  years  ago  came  to  the  conclu- 
sion that  this  cure  of  tuberculosis  of 
the  peritoneum  after  opening"  the  peri- 
toneal cavity  was  due  to  the  presence 
of  toxins  developed  from  bacteria 
which  grew  in  the  culture  medium  of 
peritoneal  exudate  exposed  by  way 
of  the  drainage-tube.  This  was  in 
fact  true,  and  the  cultures  of  tubercle 
bacilli  in  test-tubes  were  instantly 
killed  by  toxins  extracted  from  such 
fluid  and  applied  to  the  cultures. 
A    later    theory,    however,    and    one 


ABDOMEN,    SURGERY   OF    (MORRIS). 


55 


which  is  borne  out  l)y  hilcr  studies, 
is  that  the  tubercle  bacilli  are  de- 
stroyed by  phagocytes  in  the  course 
of  the  intense  h}perleucocytosis  wliich 
promptly  follows  opening'  of  the  peri- 
toneal cavity  for  any  purpose.  The 
idea  that  such  hvperleucocytosis 
proves  destructive  to  the  tubercle 
bacilli  is  further  substantiated  by  the 
fact  that  various  substances  injected 
into  the  peritoneal  cavity  have  proved 
effective  in  the  same  way,  and  for  the 
destruction  of  tubercle  bacilli  in  the 
peritoneum  it  apparently  matters 
little  which  method  for  exciting  exag- 
gerated hyperleucocytosis  is  chosen, 
so  long  as  we  bring  about  that  phe- 
nomenon. 

The  onset  of  symptoms  as  shown  by 
a  study  of  122  cases  is  often  sudden 
and  stormy,  both  in  the  cases  where 
there  is  ascitic  fluid  present  and  where 
it  is  absent.  Fluid  can  go  quickly  and 
improvement  take  place  very  rapidly 
both  with  and  without  an  operation. 
Tuberculous  peritonitis  can  be  latent, 
unsuspected,  so  far  as  symptoms  are 
concerned,  and  it  can  remain  apparently 
unchanged  for  months  after  active 
symptoms  have  subsided  and  the  pa- 
tient returned  to  apparent  health. 
Foci  for  the  infection  of  the  general 
peritoneum  have  not  been  found  in  the 
Fallopian  tubes  or  in  the  vermiform 
appendix  in  this  group  of  cases. 

Operation  should  only  be  undertaken 
when  there  is  some  distress  from  the 
distention ;  it  is  better  to  wait  for  a 
period  with  the  patient  at  rest  and 
under  the  same  hygienic  conditions  to 
which  any  case  of  pulmonary  tuber- 
culosis would  naturally  be  subjected, 
namely,  rest,  fresh  air,  good  food,  and, 
later,  mode -ate  regulated  exercise.  If 
after  six  or  eight  weeks  there  is  no 
improve-nent  in  the  symptoms  opera- 
tion should  be  considered. 

When  once  the  disease  is  arrested, 
whether  by  operation  or  hygienic  meth- 
ods of  treatment,  the  patients  must  be 
taught  to  regulate  their  lives  with  the 


same  care  that  they  would  had  their 
disease  been  located  in  the  lungs.  A. 
K.  Stone  (Boston  Med.  and  Surg. 
Tour.,  May  7,  1908). 

Ascites. — We  speak  of  surgical 
treatment  of  ascites  rather  than  of 
cirrhosis  of  the  liver  in  cases  of  the 
latter  disease,  1:)ecause  the  operation 
has  probably  little  influence  upon  the 
liver  itself.  Ascites  and  hydroperi- 
toneum  from  whatever  cause  may  be 
relieved  temporarily  by  paracentesis. 

The  incidental  laparotom}^  with 
drainage  corrects  the  condition  for 
the  time  being.  We  have  to  be  par- 
ticularly careful  to  guard  the  peri- 
toneum against  infection  in  many  of 
these  cases,  for  the  reason  that  the 
current  of  lymph  is  outward  from  the 
peritoneum,  and  it  becomes  exposed 
to  various  bacteria.  AAHien  the  cur- 
rent is  inward,  as  in  normal  condi- 
tions, there  is  destruction  of  entering 
bacteria  by  the  action  of  blood-  and 
body-  cells. 

Study  of  the  accidents  which  may 
follow  paracentesis  for  ascites.  These 
may  be  classed  into  five  principal  cate- 
gories, viz. :  serous  anemia,  icterus 
gravis,  hemorrhages  of  the  abdominal 
wall,  hemorrhages  of  the  digestive 
canal,  and  cardiac  dilatation  a  vacuo. 
1.  In  every  case  of  cirrhosis  the  physi- 
cian should  rigidl}^  insist  on  the  proper 
diet  and  treatment  and  not  waste  time 
with  half-measures.  2.  In  every  case 
of  puncture  for  ascites  the  condition  of 
the  heart  should  be  investigated,  and 
when  indicated  a  preventive  cardiac 
tonic  treatment  instituted.  All  the  ele- 
ments of  prognosis  should  be  weighed 
in  each  particular  case.  3  A  small 
trocar  should  be  used,  the  dorsal  de- 
cubitus should  be  maintained,  and  a 
very  firm  bandage  should  be  placed 
about  the  body  immediately  and  kept 
in  place  for  a  week  or  longer  if  the 
patient  gets  up.  The  place  of  election 
should  be  at  the  junction  of  the  middle 
and    outer    thirds    of    the    umbilicoiliac 


56 


ABDOMEN,    SURGERY   OF    (MORRIS). 


line.  4.  After  the  operation  the  pa- 
tient should  not  be  left,  but  should  be 
closely  watched  in  order  to  be  able  to 
institute  in  time  any  medication  which  ■ 
may  be  necessitated  by  the  occurrence 
of  any  of  the  above-mentioned  acci- 
dents. Perrin  (Presse  med.,  Sept.  23, 
1908). 

Omentopexy  or  the  Talma-Drum- 
mond  operation  has  for  its  aim  the 
establishment  of  adhesions  between 
the  omentum  and  parietal  peritoneum. 
These  adhesions  become  filled  with 
capillary  blood-vessels  in  time,  and 
the  free  network  of  small  new  vessels 
constitutes  a  A'enous  anastomosis 
around  the  area  of  obstructed  circu- 
lation. This  work  may  be  done  by  in- 
troducing numerous  pinpoint  sutures, 
or  by  pulling  the  omentum  between 
the  transversalis  fascia  and  the  pos- 
terior sheath  of  the  rectus  muscle, 
and  fixing  it  there. 

In  addition  to  establishing  a  new 
circulation  by  the  roundabout  way  of 
adhesions  of  the  omentum,  it  is  well 
to  scarify  the  cephalad  surface  of  the 
liver  and  the  corresponding  perito- 
neum of  the  diaphragm.  This  may 
be  done  very  rapidly  by  the  use  of  a 
nailbrush  with  the  bristles  cut  very 
short.  The  peritoneum  which  has 
been  denuded  of  its  endothelium  in  this 
way  throws  out  abundant  lymph  and 
makes  extensive  adhesions,  which 
later  are  filled  with  new  capillaries. 
The  operation  seldom  accomplishes 
the  object  for  which  it  is  intended  in 
a  satisfactory  way,  because  it  is 
commonly  used  as  a  last  resource 
when  changes  in  the  liver  have  be- 
come too  far  advanced.  The  opera- 
tion performed  before  ascites  has 
become  a  disturbing  feature  is  some- 
times distiilctly  of  value,  particularly 
when  the  omentum  is  fixed  to  struc- 
tures extra  to  the  peritoneum. 


The  more  popular  method  is  indirect 
anastomosis,  which  mgiy  be  done  either 
by  sewing  the  omentum  to  the  liver 
and  diaphragm,  by  sewing  the  omentum 
to  the  skin  of  the  abdominal  wall,  by 
fastening  it  between  the  outer  layer  of  , 
the  peritoneum  and  the  muscular  part 
of  the  abdominal  wall,  or  only  to  the 
surface  of  the  parietal  peritoneum. 
The  two  latter  methods  are  emploj-ed 
most  frequently.  Drainage  is  unneces- 
sary. Local  anesthesia  is  often  suffi- 
cient for  the  operation.  Of  108  cases 
which  the  author  has  collected,  58  were 
improved  or  cured,  14  were  not  im-. 
proved,  and  36  died.  The  results  in 
hypertrophic  cirrhosis  seem  to  have 
been  somewhat  better  than  in  atrophic, 
66  per  cent,  of  the  former  recovering 
and  only  45  per  cent,  of  the  latter. 
Turgard  (Annales  de  la  Polyclinique 
de  Lille,  Xos.   5  and  6,   1904). 

Three  cases  of  cirrhosis  of  the  liver 
with  ascites  in  which  the  writer  made 
an  exploratory  laparotomy  and  twelve 
others  in  which  he  performed  the 
Talma  operation.  Three  of  the  pa- 
tients in  the  latter  group  were  restored 
to  health.  The  results  are  better,  the 
earlier  the  operation  is  done.  None  of 
the  patients  was  permanently  cured 
whose  ascites  was  due  to  peritonitis 
rather  than  to  the  cirrhosis.  Lieblein 
(Mitt.  a.  d.  Grenz.  d.  Med.  u.  Chin, 
Bd.  xviii,  Nu.  5.  1908). 

The  benefit  of  the  Talma  operation 
for  Banti's  disease  is  due  to  the  lapa- 
rotomy and  the  resulting  hyperemia 
rather  than  to  the  omentopex3^  The 
latter  helps,  but  the  hyperemia  from 
the  laparotomy  is  the  main  factor,  as 
determined  in  the  course  of  10  such 
cases.  In  operating  the  writer  aims  to 
induce  hyperemia  as  much  as  possible 
and  to  remove  all  traces  of  the  ascites. 
If  the  kidneys  are  functioning  defect- 
ively, absorption  of  ascitic  fluid  left 
behind  may  prove  fatal.  He  knows  of 
two  such  deaths,  and  warns  that  pro- 
nounced kidney  disease  contraindicates 
the  operation,  and  that  in  all  cases  the 
general  anesthesia  should  be  as  slight 
as  possible.  Bogojawlensky  (Zentralbl. 
f.  Chir.,  Feb.  27,  1909). 


Congenital  Cysts  of  the  Mesentery.     (//.  C.  Deaver.) 
Annals  of  Surgery. 


ABDOMEN,    SURGERY   OF    (MORRIS). 


57 


Three  cases  in  which  the  writer  fol- 
lowed Ruotle's  method  of  treating 
chronic  ascites  with  cirrhosis  of  the 
liver  by  suturing  the  peripheral  end  of 
the  saphenous  vein,  severed  8  cm.  above 
its  mouth,  to  the  peritoneum  just  above 
Poupart's  ligament.  In  the  first  case,  a 
man  of  38,  the  patient  is  well,  with  no 
return  of  ascites  after  the  operation  a 
year  ago ;  in  this  case  omentopexy,  de- 
capsulation of  both  kidneys,  and  con- 
tinuous abdominal  drainage  had  failed 
to  cure.  In  the  2  other  cases  the 
ascites  was  the  result  of  pericarditic 
pseudocirrhosis  of  the  liver ;  here 
none  of  the  operations  done,  including 
the  Ruotle,  gave  relief.  T.  Soyesima 
(Deut.  Zeit.   f.   Chir.,  April,   1909). 

Surgery  of  the  Mesentery  and 
Omentum. — Aside  from  surgical  af- 
fections which  involve  the  mesentery 
along  with  the  intestine,  the  former 
suffers  from  surgical  affections  pecu- 
liar to  itself,  more  especially  solid 
tumors  and  cysts  in  the  omentum 
and  mesenteric  folds.  They  do  not, 
as  a  rule,  cause  acute  or  complete 
ileus,  but  cause  pressure  symptoms, 
and  if  left  alone  tend  to  set  up  low- 
grade  peritonitis  and  adhesions  to 
neighboring  viscera. 

These  growths  should  be  extirpated 
whenever  operable.  Cysts  with  dense 
adhesions  and  chylous  cysts  can  only 
be  managed  by  drainage. 

There  are  four  ways  of  dealing  with 
congenital  intramesenteric  cysts:  (1) 
by  aspiration ;  (2)  by  cystostomy  and 
drainage,  with  or  without  the  use  of 
caustics;  (3)  by  enucleation,  and  (4) 
by  resection  of  the  involved  intestinal 
segment.  The  first  method  is  obsolete, 
the  second  is  useful  in  the  presence  of 
numerous  adhesions,  the  third  is  ideal 
when  practicable,  and  the  fourth  is  the 
best  in  multiple  juxtaposed  cysts  when 
too  much  surgical  interference,  as  from 
dealing  with  cysts  one  by  one,  carries 
more  risk  than  simple  resection.  Four 
personal  cases.  H.  C.  Deaver  (Annals 
of  Surg.,  May,  1909). 


SURGICAL  DISEASES  OF  THE 

INTESTINES.— Ileus.— Most  of  the 
conditions  which  require  surgical  in- 
tervention  for  the  intestine,   excepting 
traumatisms,    are    brought    about    by 
ileus  or  intestinal  obstruction  of  some 
form.     This  is  not  the  place  to  discuss 
the   manifold   agencies    which   produce 
obstruction,    nor   their    recognition   be- 
fore operation.   Once  acute  obstruction 
is     evident,     the     surgeon     is     usually 
obliged  to  open  the  abdomen,  his  course 
afterward  depending  on  the  nature  of 
the  obstruction.    In  conditions  like  in- 
tussusception,    volvulus,      intestinal 
hernia,  or  obstruction  adhesions,  the 
obstructed  loop  is  released,  and  steps 
described  for  the  separate  conditions 
are  taken  to  prevent  a  recurrence  of 
the  trouble.     If  the  mesentery  is  too 
long,  or  the   intestine  too  mobile,  a 
reef  may  be  taken  in  the  former,  or 
the   latter .  may   be    anchored   to   the 
abdominal   wall    or    excised.      If   the 
intestine    has    become     strangulated 
and    is    gangrenous,    enterectomy    is 
indicated     with     secondary     anasto- 
mosis.     If    the    obstruction    is    from 
foreign  bodies,  as  with  round-worms 
or  gall-stones,  for  instance,  the  sub- 
stance should  be  worked  back  to  an 
empty    portion    of    intestine,    and    an 
enterectomy  or  colectomy  for  foreign 
bodies  performed.   If  the  loop  of  intes- 
tine shows  serious  changes  as  a  result 
of   obstruction,    a   temporary   artificial 
anus  may  be  advisable.     Excision  is 
seldom   required   in    such   cases.      In 
cases  of  acute  ileus  from  any  cause 
secondary    peritonitis    may    develop 
and  require  treatment   (see  Peritoni- 
tis).    While   acute   ileus   may   result 
from  stricture  or  tumors,  such  condi- 
tions are  much  more  apt  to  produce 
chronic   stenosis,  while  ultimately  if 
left  alone  will  produce  chronic  ileus. 


58 


ABDOMEN,    SURGERY    OF    (MORRIS). 


Such  cases  naturally  tend  to  come 
to  operation  before  ileus  develops. 
Benign  growths  and  cysts  of  the 
mesentery,  and  similar  formations 
which  do  not  compromise  the  integ- 
rity of  the  intestine  may  be  removed 
without  much  interference  with  the 
latter.  Tumors  of  the  gut  itself 
necessitate  excision  of  the  latter  with 
secondar}^  anastomosis,  or  establish- 
ment of  artificial  anus.  Tubercu- 
lous strictures  are  treated  by  entero- 
clusion,  or  enterostomy  for  drainage, 
excision  being,  as  a  rule,  contrain- 
dicated.  The  same  is  the  alternative 
in  inoperable  carcinoma. 

Volvulus. — Volvulus  most  often  oc- 
curs in  the  pelvic  colon,  and  conse- 
quently does  not  belong  to  this  group 
of  articles,  but  it  may  occur  in  the 
sigmoid  or  cecal  region.  In  the  latter 
case,  after  untwisting  the  volvulus 
and  separating  any  peritoneal  ad- 
hesions, a  rectal  tube  should  be 
passed  and  the  poisonous  contents  of 
the  volvulus  massaged  gently  but 
rapidly  toward  the  rectum,  provided 
that  no  gangrene  of  the  volvulus  be 
present.  The  prevention  of  recur- 
rence by  approximation  to  the  an- 
terior abdominal  wall  by  Roser's 
method  is  uncertain,  and  the  author 
favors  complete  excision  of  the  part  of 
the  bowel  engaged  in  volvulus,  as  this 
can  readily  enough  be  spared,  and  an 
end-to-end  or  lateral  anastomosis  of 
the  remaining  segment  of  bowel  ful- 
fills the  indication.  Volvulus  of  the 
cecal  region  occurs  when  there  is  a 
congenital  form  of  defect  giving  a 
sort  of  mesocecum  which  may  be 
quite  long.  Excision  of  the  cecum 
and  intestinal  anastomosis  are  pref- 
erable to  any  attempt  at  preventing 
the  recurrence  of  twisting  of  the 
cecum. 


Volvulus  of  the  small  intestine 
occurs  most  frequently  when  the  coil 
of  bowel  is  caught  by  an  adhesion 
band,  and  peristaltic  progress  may 
loop  the  bowel  in  such  a  way  as  to 
cause  torsion. 

To  test  the   viability   of   strangulated 
intestine    the    writer    proceeds    as    fol- 
lows :      He   relieves  the   constriction   at 
the    neck   of   the    sac    and    reduces    the 
affected  part   of   the   intestine   into   the 
abdominal  cavity,  but  he  retains  a  por- 
tion  of   adjacent  and  contiguous   intes- 
tine in  the  wound  so  as  to  be   able  to 
withdraw     and     inspect     the     suspected 
loop.     After  from  three  to  five  minutes 
after    reduction   he    again    inspects    the 
loop.      All    traction    on    the    mesentery 
is  thus  avoided,  and  the  intestine  is  kept 
warm  and  moist  in  its  natural  habitat. 
Infection    of    the    hernial    sac    or    ad- 
vanced  impairment   of   circulation   with 
beginning  gangrene  contraindicates  this 
method.     S.  C.  Plummer  (Surg.,  Gynec, 
and  Obstet,  June,  1911). 
Localized    paralysis    of    the    bowel 
occurring  in  typhoid  fever  may  lead 
to   this   twisting   of   the   bowel   upon 
itself,  and  the  twisted  part  can  best 
be   excised  if  the  patient's  condition 
allows  it. 

Intussusception. — In  a  child  with 
the  patient  under  an  anesthetic,  an 
intussusception  can  sometimes  be  re- 
duced by  tlie  hands  on  the  abdomen, 
but  the  last  inch  is  very  diiificult  of 
reduction,  and  we  are  likel}^  to  do 
damage  by  persistent  efforts.  There 
is  the  same  objection  to  water  injec- 
tion, as  we  cannot  know  whether  the 
last  inch  has  been  reduced  or  not. 
Furthermore  it  is  very  easy  to 
rupture  the  bowel  of  a  child.  We 
may  reduce  an  intussusception  better 
through  a  very  short  incision,  even 
though  children  bear  the  operation  so 
badly.  Perhaps  it  is  best  not  to  apply 
many  of  the  resources  for  intussus- 
ception described  in  the  older  text- 


ABDOMEN,   SURGERY   OF    (MORRIS). 


59 


books,  with  the  exception  of  operation 
by  immediate  laparotomy.  Tliere  is 
no  occasion  in  this  article  to  describe 
the  many  varieties  of  intussusception, 
because  the  principles  of  treatment 
are  practically  the  same  in  all.  Re- 
duction of  intussusception  is  so 
likely  to  be  followed  by  recurrence 
that  operation  is  an  addition  that  is 
preferable  in  many  cases.  The  part 
of  the  bowel  engaged  in  intussuscep- 
tion is  of  no  value,  and  consequently 
excision  of  the  bowel  with  anasto- 
mosis is  in  order,  unless  the  patient 
is  in  a  desperate  condition,  in  which 
case  we  may  simply  approximate  any 
two  loops  of  bowel  above  or  below 
the  intussusception  and  unite  these 
in  the  common  way  with  a  Lembert 
suture. 

Intussusception  cannot  progress 
beyond  the  point  at  which  such  anas- 
tomosis has  been  made. 

In  emergency  cases  of  intussuscep- 
tion, with  the  patient  in  extremis,  the 
author  likes  the  method  of  making  a 
quick  lateral  anastomosis  immediately 
above  and  below  the  area  involved  in 
the  intussusception.  If  two  traction 
sutures  are  used  for  approximating  the 
loops  of  bowel  to  be  anastomosed  the 
work  can  be  done  very  quickly  and 
with  little  traumatism. 

The  results  of  this  procedure  in 
emergency  cases  would  seem  almost  to 
justify  the  simple  resource  as  a  regu- 
lar procedure.  Intussusception  cannot 
progress  beyond  the  sutured  area.  The 
invaginated  part  of  the  bowel  in  the 
intussusception  may  slough  or  undergo 
subsequent  atrophic  changes  without 
adding  a  serious  feature. 

Typhlitis. — Not  readily  distinguish- 
able from  appendicitis,  and  is  usually 
treated  by  simple  opening  of  the 
abscess  and  drainage. 


Meckel's  Diverticulum. — One  of  the 
remains  of  the  vitelline  duct  is  some- 
times attached  to  the  convex  border 
of  the  intestine,  and  varies  consider- 
ably in  range,  as  well  as  in  character. 
In  some  cases  it  closely  resembles  the 
part  of  bowel  from  which  it  springs. 
Consequently  all  varieties  call  for 
their  respective  forms  of  treatment. 

Sometimes  the  entire  tube  remains 
as  an  opening  at  the  umbilicus,  but 
more  commonly  we  have  only  the 
patent  part  of  the  tube  near  the  bowel 
with  a  cord-like  remainder  extending 
to  the  umbilicus.  Foreign  bodies 
may  escape  into  this  diverticulum,  or 
ordinary  intestinal  contents  may 
result  in  exciting  inflammation;  Ad- 
hesions may  produce  angulation  of 
the  tube,  interfering  with  circulation 
and  leading  to  infection.  Sometimes 
the  diverticulum  acts  as  a  constrict- 
ing band  in  intestinal  obstruction,  in 
which  case  it  takes  part  in  acute  in- 
flammatory process  and  may  become 
gangrenous.  Volvulus  of  the  diver- 
ticulum may  occur. 

Diverticula  of  the  colon  may  occur 
at  any  point,  and  often  consist  of 
anatomic  defects  opening  into  epi- 
ploic appendages.  Increased  pressure 
within  the  bowel  at  any  time  may 
lead  to  considerable  enlargement  of 
one  or  more  such  diverticula,  and 
later  with  obstruction  and  inflam- 
mation. 

Epiploic  appendages  when  twisted 
upon  their  long  axes  may  become 
congested  and  even  gangrenous  in 
very  fleshy  patients,  but  the  treat- 
ment is  simply  for  abscess  which  fol- 
lows. 

Diverticulitis  of  the  sigmoid  region 
is  the  most  common,  giving  symp- 
toms quite  similar  to  those  of  appen- 
dicitis, excepting  for  location  of  tender- 


60 


ABDOMEN,    SURGERY    OF    (MORRIS). 


ness.  The  infiltrated  tissues  may  re- 
spond to  external  applications  of  heat 
or  cold,  but  frequently  we  must  oper- 
ate for  the  abscess  which  remains. 

Wounds,  Perforation  from  Within, 
etc. — In  cases  of  solution  of  continu- 
ity in  the  intestine,  whether  from 
penetrating-  wounds  from  without  or 
perforation  from  ulcers  within,  the 
course  of  procedure  is  the  same. 
Laparotomy  is  performed  and  the 
wound  or  perforation  sutured,  unless 
the  wounds  are  multiple  and  so  close 
together  that  suture  would  cause  too 
great  a  reduction  of  caliber,  in  which 
case  an  anastomosis  may  be  neces- 
sary. In  one  case  of  lacerated  and  con- 
tused ileum,  the  author  quickly  covered 
perforations  with  cargile  membrane 
without  suturing.  The  patient  recov- 
ered without  fistula.  If  large  blood- 
vessels have  been  wounded  they  must 
be  ligated.  In  all  these  cases  it  is  nec- 
essary to  carefully  cleanse  the  perito- 
neal cavity  in  the  vicinity.  The  ques- 
tion of  subsequent  drainage  depends 
on  the  individual  case  and  the  sur- 
geon's point  of  view. 

TYPICAL  OPERATIONS  OF 
THE  INTESTINE.— Enterorrhaphy. 
— This  term  is  applied  to  suture  of 
the  intestine  for  wounds  or  ulcers 
which  are  not  extensive  enough  to 
require  excision  and  anastomosis. 
The  chief  amount  of  intervention  is 
in  connection  with  the  external  inci- 
sions and  examination  of  the  intestine 
to  determine  the  extent  of  the  injury, 
which  may  involve  more  than  the 
bowel  itself.  Hemostasis  and  cleans- 
ing of  the  peritoneal  cavity  will 
necessarily  be  required  in  traumatism 
from  without,  as  well  as  in  perforat- 
ing ulcer  from  within.  It  will  often 
be  necessary  to  incise  the  mesentery 
in  order  to  complete  the  examination, 


and  these  incisions  must  always  be 
sutured  in  such  a  way  as  to  leave  no 
point  uncovered  by  peritoneum. 

Perforation  may,  as  a  rule,  be 
sutured  without  preliminary  excision 
of  tissue.  The  suture  should  run 
parallel  with  the  long  diameter  save 
when  the  traumatism  is  near  the 
pylorus.  In  this  locality  it  should  be 
applied  in  the  transverse  diameter. 
It  is  exceptional  for  an  external 
traumatism  to  consist  onl}^  of  a  single 
perforation  of  the  intestine,  for,  as  a 
rule,  not  only  is  the  bowel  itself 
penetrated  doubly,  but  other  portions 
of  intestine  and  mesentery  are  in- 
volved in  the  knife  or  bullet  wound. 
Hence  single  isolated  trauma  occurs 
most  naturally  from  the  internal 
perforations. 

]\Iultiple  perforations  of  the  bowel 
and  mesentery  are  adaptable  for 
suture,  no  matter  how  numerous,  if 
they  are  not  too  close  together;  but, 
when  a  portion  of  bowel  is,  so  to 
speak,  riddled  by  bullet  or  other 
wounds,  it  should  be  excised,  unless 
the  author's  resource  in  one  case 
quoted  above  introduces  a  principle  in 
addition. 

For  suturing  perforations  a  few 
points  of  interrupted  Lembert  silk  or 
linen  suture  are  usually  sufficient. 
In  multiple  perforation  or  when  there 
is  suspicion  of  such,  it  is  advisable 
to  suture  as  soon  as  the  wound  is 
located,  and  before  proceeding  with 
further  examination. 

The  rule  for  determining  the  pos- 
sible limit  of  suture  in  contrast  to 
excision  is  this :  if  the  suture  of  one 
or  more  openings  does  not  diminish 
the  caliber  of  the  intestine  by  more 
than  a  third,  suture  is  indicated  in 
place  of  excision. 

In  perforation  from  typhoid   ulcer 


ABDOMEN,    SURGERY   OF    (MORRIS). 


61 


multiple  traumatism  is  unusual,  and 
the  lesion  in  most  cases  is  seated  not 
far  from  the  ileocecal  valve.  ( )wing 
to  the  general  state  of  the  patient  the 
operation  must  be  rapidly  done,  as  a 
rule.  An  appendicitis  incision  usually 
suffices. 

The  perforation  is  closed  at  once 
by  a  few  interrupted  sutures,  or  a 
purse-string  suture.  Cases  of  typhoid 
perforation  do  occur  in  which,  either 
from  the  size,  number  or  complica- 
tions of  the  lesion,  enterostomy  or 
enterectomy  is  required,  but  the  con- 
dition of  the  patient  sometimes  makes 
it  desirable  to  quickly  fasten  the 
bowel  opening  near  to  the  external 
opening,  and  to  do  a  secondary  exci- 
sion operation  after  recovery  from 
the  typhoid.  The  friable  character 
of  tissues  distended  with  serous  in- 
filtrates also  makes  this  expediency 
work  necessary  when  the  friable  tis- 
sues refuse  to  bend  freely  to  sutures. 
Even  after  simple  suture  it  may  not 
be  advisable  to  close  the  abdominal 
wound,  in  contradistinction  to  the 
course  pursued  in  suture  of  external 
wounds.  The  presence  of  peritonitis 
with  adhesions  may  make  it  advan- 
tageous to  leave  the  lower  angle  of 
the  wound  open  for  the  purpose  of 
a  little  drainage. 

Review  of  the  literature  of  intestinal 
perforation  in  typhoid  fever  showed 
that  those  operated  upon  in  which  per- 
foration was  found  consisted  of  269 
cases  (from  1903  to  1909)  ;  156  of  this 
num-ber  resulted  fatally,  giving  a  mor- 
tality of  57.99  per  cent.,  while  Harte 
and  Ashhurst  (all  cases  from  1884  to 
1903),  in  a  similar  study,  found  311 
cases,  with  a  mortality  of  73.31  percent. 
While  it  is  true  that  in  the  number  of 
cases  reported  during  the  previous 
twenty  years  the  proportion  should  be 
much  greater,  when  we  consider  the 
rapid  strides  in  other  abdominal  oper- 


ations during  this  period,  it  is  also  true 
that  the  mortality  shows  improvement, 
but  certainly  this  improvement  is  not 
as  great  as  has  been  accomplished  in 
other  surgical  conditions.  During  the 
period  1903-1909  nothing  new  has  been 
developed  which  will  aid  in  the  diag- 
nosis, and,  while  a  great  deal  has  been 
said  about  treatment,  very  little  real 
value  has  been  adde  ".  to  the  treatment. 
Charles  Bagley,  Jr.  (Surg.,  Gynec,  and 
Obstet.,  Aug.,  1911), 

In  a  search  through  the  literature 
since  1903,  the  writer  found  133  re- 
ported cases  of  typhoid  fever  in  which 
perforation  occurred  and  was  closed 
by  suture.  Of  this  number  68.5  per 
cent,  died  and  31.5  per  cent,  recovered. 
When  we  compare  the  percentage  of 
recoveries  with  the  figures  of  Harte 
and  Ashhurst's  25.97  per  cent.,  made  in 
1904,  and  Piatt's  20.3  per  cent.,  made 
in  1899,  and  Keen's  19.36  per  cent., 
made  in  1898,  and  Fitz's  10  per  cent., 
made  in  1891,  we  cannot  help  but  con- 
clude that -real  progress  is  being  made 
in  dealing  with  this  heretofore-fatal 
complication  of  typhoid  fever.  Com- 
bining his  own  133  cases  with  the  362 
collected  by  Harte  and  Ashhurst,  we 
have  a  grand  total  of  495  cases,  of 
which  27.4  per  cent,  recovered  and 
72.53  per  cent.  died.  These  figures 
probably  express  fairly  accurately  the 
results  of  the  surgical  treatment  of  per- 
foration in  typhoid  at  the  present  time. 
G.  D.  Head  (Jour.  Minn.  State  Med. 
Assoc,  Aug.  1,  1911). 

Enterectomy. — Excision  of  portions  | 
of  intestine  is  performed  for  a  great 
variety  of  conditions,  such  as  trau- 
matism, malignant  tumors,  actual  or 
impending  gangrene,  etc.  It  is  indi- 
cated, therefore,  as  an  operation  of 
choice  or  necessity  in  many  of  the 
conditions  which  constitute  or  give 
rise  to  ileus.  The  part  to  be  removed 
may  vary  in  length  from  two  or  three 
inches  to  a  number  of  feet.  In  enter- 
ectomy, as  in  similar  operations,  the 
actual  operation  requires  much  less 
time  and  a  much  simpler  technique 


62 


ABDOMEN,    SURGERY    OF    (MORRIS). 


than  the  secondary  stage  of  restoring 
the  continuity  of  the  intestine.  There 
is  in  fact  but  one  technique  for  the 
former,  while  the  latter  is  not  only 
practicable  by  quite  different  opera- 
tions, but  each  operation  may  be  per- 
formed by  a  number  of  different 
methods. 

For  the  performance  of  the  enter- 
ectomy  proper,  it  is  necessary  to 
excise  a  portion  of  intestine  with  a 
certain  amount  of  mesentery.  After 
the  external  incisions  and  exploration 
of  the  abdomen  the  portion  of  intes- 
tine to  be  excised  is,  if  necessary, 
freed  from  adhesions.  This  coil  of 
intestine  should  be  milked  into  the 
portions  of  the  gut  continuous,  for 
which  purpose  the  fingers  of  assist- 
ants must  be  used.  After  one-half  of 
I  the  coil  is  thus  emptied  in  one  direc- 
tion the  fingers  should  compress  the 
gut  to  prevent  re-entrance  of  intes- 
tinal contents ;  the  other  extremity  is 
then  similarly  treated.  Instead  of 
the  fingers  of  assistants,  clamps  may 
be  applied,  one  at  either  end  and 
some  inches  beyond  the  segment  of 
gut  to  be  excised.  Loops  of  gauze 
may  also  be  used,  but  in  such  a  case 
the  mesentery  must  be  penetrated, 
and  it  is  best  to  use  the  fingers  of 
assistants  as  far  as  possible. 

Before  excising,  the  mesentery 
must  be  ligated  off  close  to  the  intes- 
tine,— about  one  inch  distance.  An 
approximate  rule  is  to  place  a  catgut 
ligature  for  every  inch  of  mesentery. 
Another  is  to  ligate  less  rather  than 
more  mesentery  than  is  apparently 
called  for.  This  is  done  on  the  prin- 
ciple of  overcorrection,  because  if  too 
much  mesentery  is  sacrificed  the 
edges  of  the  anastomosis  to  be  per- 
formed may  suffer  gangrene  from 
interference  with  blood-supply. 


When  all  preliminaries  have  been 
completed  the  gut  with  its  mesenteric 
stump  is  removed  by  means  of  the 
scissors. 

Series  of  22  cases  in  which  from  192 
to  520  cm.  of  the  small  intestine  were 
resected  for  various  reasons.  The  pa- 
tients did  not  seem  to  be  incommoded 
by  the  loss  of  such  a  stretch  of  intes- 
tine, and  all  were  in  good  health  at  last 
accounts,  except  for  a  tendency  to 
diarrhea  in  a  few  cases  and  the  death 
of  one  patient  three  weeks  after  re- 
moval of  cancer  with  metastases.  In  a 
personal  case  described,  on  account  of 
sarcoma  of  the  root  of  the  mesentery, 
the  author  removed  the  entire  ileum  and 
part  of  the  jejunum,  a  total  resection 
of  510  cm.,  or  17  feet,  of  the  small 
intestine.  The  patient  gained  twelve 
pounds  in  three  months,  with  normal 
stools,  but  the  malignant  disease  re- 
curred after  five  months,  and  the  pa- 
tient, a  blacksmith  of  21,  was  dismissed 
as  incurable.  No  metastases  were  de- 
tected at  the  primary  operation.  The 
good  functional  results  in  these  cases 
justify  resection  of  two-thirds  or  even 
more  of  the  small  intestine  when  re- 
quired. Storp  (Deut.  Zeit.  f.  Chir.,  Bd. 
Ixxxvii,  Nu.  4-6,  1907). 

Research  on  dogs  and  pigs,  showing 
the  late  effects  on  the  animals  of 
various  operations  on  the  large  intes- 
tine. The  animals  all  became  emaci- 
ated  or  died  after  unilateral  subtotal 
exclusion  or  resection  of  the  large  in- 
testine with  ileosigmoidostomy.  On  the 
other  hand,  the  animals  bore  without 
apparent  injury  resection  of  the  ileo- 
cecal segment.  Simple  ileosigmoid 
anastomosis  also  proved  harmless  for 
dogs  and  pigs,  both  at  the  time  and 
months  later.  Simple  ileosigmoid 
anastomosis,  however,  always  proved 
fatal  for  herbivorous  animals,  as  also 
exclusion  of  the  large  intestine. 
Total  exclusion  of  the  large  intestine, 
with  an  anus  at  the  end  of  the  small 
intestine,  always  entailed  the  death 
of  the  dogs  in  tjn  days  and  of  the 
pigs  in  thirty — sooner  than  in  death 
from  starvation.  Alglave  (Revue  de 
Gynec,  Pozzi's,  vol.  xi,  No.  1,  1907). 


ABDOMEN,    SURGERY    OF    (MORRIS). 


63 


111  5  pcrsoiKil  cases  of  resection  of 
the  small  intestine  f<ir  .qani^rene  the 
length  removed  varied  from  one  foot 
five  and  a  half  inches  to  nine  feet  six 
inches.  Four  patients  recovered,  none 
being  under  50  years  of  age;  the  oldest 
was  65  years.  The  recoveries  were 
smooth,  without  high  temperature. 
Three  of  the  patients  did  well  subse- 
quently; the  fourth,  a  woman.  59  years 
of  age,  from  whom  nine  and  a  half 
feet  of  intestine  were  removed,  suc- 
cumbed to  a  steadily  progressing  maras- 
mus after  seven  months,  showing  that 
at  that  age  the  removal  of  half  the 
small  intestine  is  unsafe.  Whatever 
the  length  of  resected  intestine  might 
be,  the  anastomosis  must  be  in  abso- 
lutely healthy  tissue.  Lateral  anas- 
tomosis should  be  the  rule  whenever 
practicable.  The  cases  were  all  emer- 
gency cases  of  gangrenous  hernise. 
Childe    (Practitioner,  March,  1909). 

There  have  been  reported  since  1906 
but  three  or  four  successful  cases  of 
enterectomy  in  children  under  1  year. 
The  authors'  case  was  a  female  infant, 
aged  7  months,  with  irreducible  intus- 
susception ;  temperature,  100° ;  pulse, 
164;  respirations,  36.  A  resection  of 
the  bowel  was  made,  including  the 
cecum,  appendix,  and  a  part  of  the 
colon.  The  operation  was  successfully 
performed  under  spinal  anesthesia, 
using  Gray's  stovaine,  dextrin,  and 
saline  solution.  A  second  injection  of 
stovaine  was  given  just  before  anasto- 
mosis was  made,  as  the  patient  was  be- 
ginning to  show  signs  of  shock — the 
effects  of  the  first  injection  having  be- 
gun to  wear  off.  The  authors  believe 
that  the  spinal  anesthesia  saved  the 
child's  life,  while  chloroform  anes- 
thesia would  have  proved  fatal.  The 
child  received  three  pints  of  saline 
solution  daily  by  the  rectum  and  sub- 
cutaneously  for  five  days  before  nour- 
ishment was  begun,  with  small  doses  of 
morphine.  Spinal  anesthesia  cases 
show  practically  no  shock.  The  Mur- 
phy button  used  in  the  operation 
passed  in  eighty-two  hours.  Fairbank 
and  Vickers   (Lancet,  Feb.  5,   1910). 

Rapid  resection  of  the  gut  may  be 
performed  by  dropping  half  a  Murphy 


button  in  each  end  of  the  gut;  tying  up 
the  ends  of  the  gut  with  fine  silk  liga- 
tures, and  disinfecting  them  with  car- 
bolic acid ;  pushing  the  halves  of  the 
button  together  to  complete  the  anas- 
tomosis; closing  the  V  of  the  mesentery 
with  a  stitch ;  and  finally,  drawing  the 
wound  together  with  a  silkworm-gut 
suture.  In  respect  to  the  after-treat- 
ment, water  is  given  at  once,  and  the 
stomach  washed  out  with  a  tube,  as 
required.  After  twenty-four  hours,  al- 
bumin water  and  beef-juice  are  given, 
and  after  forty-eight  hours  malted 
milk.  No  laxatives  or  hard  foods  are 
given  for  a  week.  The  bowels  are 
moved  in  three  or  four  days  by  enemata 
or  suppositories. 

This  combination  of  methods  is  suit- 
able for  any  case  demanding  resection 
of  the  small  intestine,  and  is  especially 
useful  if  great  haste  is  required.  It  may 
be  done  under  local  anesthesia,  espe- 
cially if  morphine  and  hyoscine  are 
used.  W.  L.  Wallace  (Amer.  Jour. 
of  Surg.,  Feb.,  1911). 

Enteroanastomoses. — These  meth- 
ods of  restoring  continuity  of  the 
intestine  after  enterectomy  comprise 
three  distinct  types.  The  first  and 
most  natural  is  end-to-end  anasto- 
mosis or  suture,  which  in  most  cases 
is  the  operation  to  choose. 

The  second  type  is  known  as  the 
side-to-side  laterolateral  or  simply 
lateral.  It  differs  in  scope  from  the 
preceding  chiefly  because  it  may  be 
used  between  the  small  and  large 
intestines,  and  small  intestines  and 
stomach. 

The  third  type  is  known  as  end-to- 
side  or  terminolateral,  or  simply  as 
the  implantation  method.  It  is  re- 
stricted in  practice  to  implantation  of 
a  cut  end  of  small  intestine  into  the 
stomach  or  colon.  The  first-named 
has  already  been  considered  in  part 
under  pylorectomy.  The  latter  is 
specifically  known  as  ileocolostomy, 
or  ileosigmoidostomy. 


64 


ABDOMEN,    SURGERY    OF    (MORRIS). 


Gastroenterostomy.  —  This  opera 
tion  consists  of  a  lateral  anastomosis 
between  the  stomach  and  some 
portion  of  the  small  intestine,  either 
the  duodenum  or  jejunum.  Accord- 
ing as  the  intestine  is  united  to  the 
anterior  or  posterior  stomach  wall 
the  operation  is  known  as  anterior  or 
posterior  gastroenterostomy. 

The  operation  is  indicated  in 
certain  cases  of  gastric  or  duodenal 
ulcer,  either  as  a  primary  resource  or 
one  secondary  to  pylorectomy  or  gas- 
trorrhaphy.  Generally  speaking  the 
operation  is  one  of  necessity  when 
milder  measures  have  failed  or  are 
likely  to  fail.  Minor  indications  for 
gastroenterostomy  are  found  in  con- 
traction of  the  pylorus  from  swallow- 
ing corrosive  poison,  in  congenital 
hypertrophic  stenosis  of  the  pylorus, 
and  finally  in  certain  cases  of  cancer 
in  this  locality,  as  a  palliative  when 
pylorectomy  cannot  be  performed. 

Roentgen-ray  pictures  taken  before 
the  operation  and  soon  after  and  again 
after  an  interval  of  a  year  or  so  in  22 
cases.  They  showed  that  the  stomach 
evacuation  proceeded  after  a  gastro- 
enterostomy not  merely  by  the  laws  of 
gravity,  but  by  a  kind  of  physiologic 
sphincter  process.  The  cases  teach  fur- 
ther that  when  the  new  opening  is  made 
on  account  of  anr.tomic  stenosis  it 
answers  the  desired  purpose  completely 
from  the  practical  point  of  view.  When 
the  stenosis  was  merely  spastic  the  gas- 
troenterostomy overcomes  the  tendency 
to  contraction  and  the  pylorus  becomes 
permeable  once  more.  Conversely,  an 
ulcer  in  the  middle  part  of  the  stomach 
is  not  much  influenced  by  the  gastro- 
enterostomy; most  of  the  food  still 
passes  out  through  the  pylorus  instea^d 
of  through  the  new  opening.  One  or 
more  internal  courses  of  treatment  for 
the  ulcer  should  follow  every  gastro- 
enterostomy. Hartel  (Deut.  Zeit.  f. 
Chir.,  April,  1911). 


Examination  of  40  patients  to  ascer- 
tain present  conditions  after  a  gastro- 
enterostomy, and  analysis  of  the  find- 
ings in  25,  including  13  cases  in  which 
the  pylorus  was  resected.  The  findings 
taught  the  necessity  of  making  the 
opening  at  the  lowest  point  of  the 
stomach  after  resection,  and  also  that 
the  gastric  digestion  nearly  always  suf- 
fers after  a  gastroenterostomy.  Schiil- 
ler  (Mitteil.  a.  d.  Grenz.  d-r  Med.  u. 
Chir.,  Bd.  xxii,  Nu.  5,  1911). 

The  operation  is  contraindicated  in 
so-called  medical  diseases  of  the 
stomach,  however  severe  these  may 
be. 

The  ideal  operation  is  one  in  which 
the  opening  is  made  as  nearly  as  we 
can  to  the  pylorus  and  the  proximal 
loop  of  jejunum,  thus  utilizing  the  part 
of  the  stomach  which  is  commonly  the 
lowest  during  the  process  of  diges- 
tion. This  will  allow  free  regurgita- 
tion to  the  alkaline  intestinal  juices. 
Anastomosis  with  the  cardiac  part 
of  the  stomach  would  allow  acid 
contents  to  escape  in  case  of  good 
digestion,  and  defect  of  pyloric  diges- 
tion would  be  the  result.  In  addition, 
cases  have  been  reported  in  which 
jejunal  ulcer  has  followed  the  form- 
ing of  an  opening  at  a  point  where 
acid  contents  could  injure  the  tissues. 
The  choice  of  procedure  in  gastro- 
enterostomy at  the  present  time  is 
probably  the  so-called  posterior  no- 
loop  operation,  and  the  author  has 
referred  to  older  operations  which 
are  necessary  at  times.  Even  with 
ulcer  of  the  stomach  in  the  cardiac 
end  of  the  stomach,  the  posterior  no- 
loop  operation  should  be  made  with 
the  pylorus,  if  possible,  to  avoid  the 
efifects  of  gastric  acidit}^  at  some 
distant  point  from  the  pylorus.  The 
posterior  no-loop  operation  is  per- 
formed     by      making      an      opening 


ABDOMEN,    SURGERY    OF    (MORRIS). 


65 


through  the  transverse  mesocolon  in 
the  usual  way,  avoiding-  the  middle 
colic  vessels.  The  posterior  surface 
of  the  stomach  being  exposed,  a 
portion  near  the  pylorus  part  is 
chosen  and  drawn  throug'h  the  open- 
ing-. The  jejunal  flexure  close  to  the 
duodenum  is  found  l)eneath  the  left 
of  the  mesocolon,  and  the  proximal 
loop  is  employed  for  completing  the 
gastroenterostomy,  but  in  such  a  way 
thai:  when  the  parts  are  released  from 
the  fingers  or  clamps  the  intestine 
will  hang  in  a  direction  which  is 
almost  vertical,  but  with  a  slight 
inclination  toward  the  left  or  right, 
in  a  normal  line  of  the  long  axis  of 
the  individual  jejunum.  This  is  the 
essential  part  of  the  posterior  no-loop 
operation. 

Conclusions  based  on  214  gastro- 
enterostomies. The  operation  gives  the 
best  results  in  cases  in  which  there  is 
organic  disease  in  the  prepyloric  or 
pyloric  regions  of  the  stomach  or  duo- 
denum, or  when  performed  on  the  car- 
diac side  of  a  stenosis  in  the  body  of 
the  stomach.  When  an  ulcer  is  found 
on  the  lesser  curvature  near  the  cardia 
it  should  be  excised,  if  possible ;  gas- 
troenterostomy is  not  necessary,  and  if 
performed  is  either  almost  useless  or 
entirely  harmful.  When  there  is  a 
suspicion  of  malignancy  in  an  ulcer  or 
ulcers  in  the  pyloric  region,  Rodman's 
operation  should  be  performed.  Under 
no  circumstances,  and  in  compliance 
with  no  persuasion,  however  insistent, 
is  gastroenterostomy  to  be  done  in  the 
absence  of  demonstrable  organic  dis- 
ease. Regurgitant  vomiting,  formerly 
the  most  troublesome  of  all  complica- 
tions, is  dependent  on  faults  in  the 
operation  which  result  in  some  me- 
chanical obstruction  to  the  intestine. 
These  faults  are  chiefly  dependent  on 
the  presence  of  a  loop  in  the  jejunum, 
but  may  also  be  caused  by  a  twist  in  the 
intestine  around  its  longitudinal  axis  at 
the  time  of  its  application  to  the  stom- 
ach.    The    posterior    no-loop    operation 


with  the  vertical  application  of  the 
bowel  to  the  stomach  is  the  best  pro- 
cedure. Moynihan  (Brit.  Med.  Jour., 
May  9,  1908). 

If  the  edges  of  the  cut  mesocolon 
are  fastened  to  the  stomach  wall 
before  completing  this  gastroenteros- 
tomy, it  will  obliterate  the  opening  in 
the  mesocolon,  and  this  is  desirable 
for  avoiding  subsequent  hernia,  if  the 
patient's  condition  allows  us  to 
follow  ideal  technique.  When  adhe- 
sions or  extensive  scarring  or  other 
mechanical  reasons  make  the  poste- 
rior no-loop  operation  of  gastrojejunos- 
tomy difficult,  we  may  use  gastroduo- 
denostomy  instead.  The  anterior  wall 
of  the  pylorus  is  joined  with  the  de- 
scending part  of  the  duodenum,  but 
where  we  suture  the  mesocolon  to  the 
stomach  it  avoids  the  danger  of  sub- 
sequent hernia. 

The  most  frequent  source  of  bad  re- 
sults after  gastroenterostomy  is  a  posi- 
tion of  the  fistula  causing  the  food  to 
enter  that  part  of  the  bowel  which  leads 
back  to  the  stomach.  To  avoid  this 
the  loop  of  the  intestine  selected  must 
be  as  close  as  possible  to  the  stomach, 
and  not  the  first  loop  that  comes  to 
hand;  again,  it  sliould  always  be  sewed 
antiperistaltic.  Finally,  the  opening  in 
the  stomach  must  not  be  larger  than 
the  lumen  of  the  loop  of  bowel.  If 
these  rules  are  followed  there  will 
probably  be  no  trouble.  Delaloye 
(Deut.  Zeit.  f.  Chir.,  Bd.  Ixxxiii,  Nu. 
6,  1906). 

Report  of  3  cases  of  gastrojejunal 
and  jejunal  ulceration  foll-^wing  gastro- 
enterostomy. There  was  a  recurrence 
of  gastric  symptoms,  in  1  case  a  few 
weeks  after  the  gastroenterostomy,  in 
the  others  two  years  after.  In  accord 
with  the  observations  of  others,  the 
author  concludes  as  follows : — 

1.  Two  types  of  jejtmal  ulceration 
must  be  distinguished,  the  one — gastro- 
jejunal— in  which  the  ulceration  occurs 
at  the  site  of  the  anastomosis ;  the  other 
— true  jejunal  ulceration — in  which  one 


1—5 


66 


ABDOMEN,    SURGERY    OF    (MORRIS). 


or  more  ulcers  form  in  the  jejunum  at 
some  distance  from  the  anastomotic 
opening.  2.  In  the  great  majority  of 
cases  the  ulceration  uas  occurred  at  or 
close  to  the  gastrojejunal  anastomosis. 
3.  The  ulceration  may  manifest  itself  at 
any  period  after  the  gastroenterostomy 
operation,  from  a  few  weeks  to  several 
years.  4.  The  formation  of  the  ulcer 
is  usually  associated  with  a  recurrence 
of  the  gastric  symptoms,  but  in  some 
cases  symptoms  of  perforation  have 
been  the  first  evidence  of  the  ulceration. 
5.  The  tendency  to  perforation  is  ap- 
parently greater  than  in  the  case  of 
gastric  ulcer,  and  the  death  rate  from 
such  perforation  is  high.  6.  In  all  the 
recorded  cases  the  preceding  gastro- 
enterostomy has  been  carried  out  for 
the  relief  of  a  non-niaiignant  affection 
of  the  stomach  or  duodenum  (Key 
has  recorded  1  case  as  jejunal  ulcer 
after  gastroenterostomy  for  gastric 
carcinoma,  but  the  eA'idence  is  uncon- 
vincing). 7.  Jejunal  ulceration  has 
been  met  with  after  every  variety  of 
gastroenterostomy,  but  it  occurs  prob- 
ably more  frequently  after  an  en  Y 
type  of  anastomosis  than  after  the 
simpler  forms  of  operation.  8.  In  the 
majority  of  cases  the  preceding  gastric 
lesion  had  been  associated  with  hyper- 
acidity, but  in  not  a  few  cases  there  had 
been  no  excess  of  free  acid.  9.  The 
jejunal  ulceration  is  probably  caused  by 
the  action  of  the  acid  gastric  juice  on 
the  jejunal  mucosa,  which,  under  nor- 
mal conditions,  is  exposed  to  an  alka- 
line medium.  T.  P.  D.  Wilkie  (Edin- 
burgh Med.  Jour.,  Oct.,  1910). 

Analysis  of  48  cases  of  gastroenteros- 
tomy for  ulcer  of  the  stomach.  There 
were  IS  deaths,  in  1  of  which  the 
patient,  after  an  uneventful  progress 
for  fifteen  days  after  operation,  suc- 
cumbed to  peritonitis  induced  by  a 
gangrenous  appendix,  the  site  of  opera- 
tion not  being  affected.  The  case  is  an 
argument  in  favor  of  appendicectomy 
with  every  gastroenterostomy.  In  2 
other  cases  death  was  due  to  carcinoma 
after  apparent  recovery.  In  the  major- 
ity of  patients  who  died,  surgical  treat- 
ment should  have  been  resorted  to 
earlier,  as  shown  by  the  advanced  de- 


gree of  stenosis  shown  at  operation.  In 
21  of  the  48  cases  there  was  ulcer  of 
the  stomach  or  duodenum  with  stenosis, 
and  14  of  these  patients  recovered  per- 
fectly, and  only  1  was  vmimproved. 
There  were  3  patients  operated  on  with 
ulcer  without  stenosis;  1  recovered,  1 
has  improved,  and  1  remains  unim- 
proved. J.  D.  Dunham  (Jour.  Amer. 
Med.  Assoc,  Nov.  19,  1910). 

First  instance  in  the  human  being 
where  the  proposed  fistuloenterostomy 
of  von  Subenrauch  was  carried  out' 
successfully.  This  procedure  uses  a 
diverted  segment  of  intestine  as  a  canal 
to  carry  the  discharge  from  a  biliary  fis- 
tula back  into  the  intestinal  tract.  Sut- 
ton   (Annals  of  Surg.,  Sept.,   1910). 

Experimental  research  by  the  writer 
confirming  the  view  that  peptic  ulcers 
after  gastroenterostomy  are  due  to  the 
action  of  the  acid  gastric  juice  on  the 
intestinal  mucosa,  and  that  this  acidity 
should  be  neutralized  with  alkalies  in 
prophylaxis.  After  a  gastroenterostomy 
the  patient  should  keep  up  an  ulcer  diet 
for  a  long  time.  The  author's  experi- 
ence indicates  that  the  posterior  retro- 
colic  gastroenterostomy  according  to 
von  Hacker,  as  near  to  the  duodenum  as 
possible,  is  the  operation  that  is  least 
liable  to  be  followed  by  a  peptic  ulcer. 
Exalto  (Mitteil.  a.  d.  Grenz.  der  Med. 
u.  Chir.,  Bd.  xxiii,  Nu.  1,  1911). 

Anterior   Gastroenterostomy. 

— This,  the  original  procedure,  has 
been  replaced  in  most  cases  by  the 
posterior  operation,  but  is  still  per- 
formed when  the  posterior  wall  is 
unaccessible  by  reason  of  adhesions 
or  organic  disease.  A  fairly  good 
rule  is  for  the  surgeon  to  do  which- 
ever operation  he  can  do  most  easily 
in  any  given  case,  but  the  anterior 
operation  gives  more  postoperative 
complications.  The  operation  is  as 
follows : — 

After  the  stomach  has  been  fully 
exposed,  its  anterior  wall  is  so 
grasped  that  the  fold  which  is  to  be 
the    seat    of    the    anastomosis    runs 


ABDOMEN,    SURGERY    OF    (MORRIS). 


Q 


o1)liqnely  across  from  ris^iit  to  left, 
and  from  below  upward.  'I^he  intes- 
tine is  similarly  grasped  about 
eig'hteen  inches  below  the  duodeno- 
jejunal junction  and  the  two  struc- 
tures placed  side  by  side. 

The  anastomosis  is  then  carried 
out  as  in  all  similar  procedures,  one- 
half  the  outer  plane  of  sutures  being 
inserted  before  the  incision  is  made. 
Details  of  technique  may  be  con- 
sidered under  the  posterior  operation. 

Posterior  Gastroenterostomy. — The 
external  incision  is  that  used  for 
other  operations  on  the  lower  portion 
of  the  stomach  and  the  pylorus, 
passing  through  the  right  rectus 
by  blunt  dissection,  the  posterior 
sheath  and  peritoneum  being  divided 
together.  The  incision  is  largely  an 
exploratory  one,  for  despite  the  evi- 
dence of  a  pyloric  ulcer,  for  example, 
the  entire  stomach  and  duodenum 
with  the  neighboring  viscera  must  be 
examined  for  complications  and  pos- 
sible contraindications.  The  jejunum 
must  also  be  examined  with  especial 
reference  to  its  relations  with  other 
organs.  The  natural  direction  should 
be  learned,  for  this  ma}^  be  to  the 
right,  left,  or  directly  downward,  and 
in  bringing  the  intestine  in  contact 
with  the  posterior  wall  the  original 
direction  must  be  conserved. 

The  results  of  different  methods  of 
posterior  gastroenterostomy  show  that 
there  is  no  "natural  direction"  of  the 
jejunum,  and  consequently  no  "best 
line"  for  anastomosis.  One  is  as  good 
as  another,  provided  no  twist  be  given 
to  the  gut  at  the  time  of  anastomosis. 
The  main  point  is  to  choose  for  the 
anastomosis  that  part  of  the  jejunum 
which  is  close  to  the  flexure.  This  line 
can  be  directly  approximated  to  the 
stomach  without  the  gut  being  re- 
volved on  its  longitudinal  axis.  Moy- 
nihan  (Annals  of  Surg.,  April,  1908). 


In  order  to  gain  access  to  the 
l)osterior  wall  it  is  necessary  to  go 
through  the  transverse  mesocolon, 
the  incision  being  ample  enough  to 
enable  the  posterior  wall  to  be  drawn 
outward;  but  the  incision  in  the  meso- 
colon, to  avoid  opening  large  blood- 
vessels, should  be  first  made  small, 
and  then  enlarged  by  stretching  with 
the  fingers. 

Generally  speaking  the  portion  of 
this  wall  to  be  selected  for  anasto- 
mosis is  at  the  lowest  point  of  the 
organ,  which  is  considerably  nearer 
to  the  pylorus  than  to  the  cardia  and 
fundus.  The  author  likes  to  cut 
through  the  ligament  of  Treitz  when 
approaching  the  posterior  stomach 
wall.  This  brings  one  to  a  convenient 
part  of  the  jejenum  for  the  no-loop 
operation.  He  prefers  traction  sutures 
rather  than  instruments  for  approxi- 
mating stomach  and  ileum  during  op- 
erative procedure.  The  portion  to  be 
incised  for  the  anastomosis  is  pinched 
up  in  a  direction  corresponding  to  the 
natural  direction  of  the  jejunum  itself. 
The  latter  is  also  grasped  an  inch  or 
two  below  the  duodenojejunal  junction. 
As  in  all  such  anastomoses,  a  portion 
of  the  outer  plane  of  sutures  is  intro- 
duced before  the  incisions  are  made. 
This  is  a  continuous  seromuscular 
sutlire,  intended  to  fix  the  two 
structures  together  and  furnish  a 
guide  to  the  incisions.  The  latter, 
some  three  inches  in  length,  are  not 
simple  linear  incisions,  but  a  small 
spindle-shaped  portion  of  tissue  is 
excised.  The  two  openings  thus 
made  are  now  sutured  together  by 
through-and-through  stitches  of  the 
penetrating  type,  the  two  posterior 
margins  being  first  united,  and  then 
the  anterior  margins,  the  inner  layer 
of     sutures    being    thus     completed. 


68 


ABDOMEN,   SURGERY   OF    (MORRIS). 


The  fingers  or  clamps  are  removed, 
and  the  outer  plane  of  serous  sutures 
completed. 

In  performing  the  posterior  operation 
the  writer  advises  that  the  operator 
locate  the  peritoneal  suspensory  liga- 
ment or  band  which  extends  from  the 
transverse  mesocolon  to  the  upper  part 
of  the  jejunum.  Immediately  above 
this  band,  in  the  mesocolon,  is  an  area 
in  which  there  are  no  important  blood- 
vessels. The  suspensory  band  having 
been  stripped  away,  and  a  transverse 
incision  made  in  the  above-mentioned 
area  of  the  mesocolon,  the  posterior 
aspect  of  the  stomach  may  be  drawn 
through  this  opening  and  the  denuded 
jejunum  attached  to  it,  the  attachment 
thus  being  without  strain  or  loop  and 
following  the  normal  direction  of  the 
jejunum.  Mayo  (Annals  of  Surg., 
Jan.,  1908). 

Roux's  Operation. — The  Y-opera- 
tion  of  Roux  differs  notably  from  the 
typical  procedures  just  enumerated, 
being-  a  combination  of  the  anasto- 
moses, both  being-  examples  of  im- 
plantation of  terminolateral  anasto- 
moses. The  jejunum  having  been 
divided  across,  the  peripheral  seg-- 
ment  is  implanted  into  the  posterior 
surface  of  the  stomach,  while  the 
proximal  segment  is  implanted  into 
the  jejunum. 

It  is  no  longer  held  desirable  to  use 
mechanical  devices  in  most  gastro- 
enterostomies, although  such  aids 
were  of  great  importance  at  one  time 
in  giving  us  confidence  to  advance 
to  a  simpler  technique. 

Gastroenterostomy  is  liable  to  be 
succeeded  by  certain  typical  compli- 
cations. Among  these  are  hemor- 
rhages., sometimes  inexplicable,  but 
now  generally  believed  to  be  due  fre- 
quently to  overlooked  ulcers,  or  to 
imperfect  suturing,  or  to  the  use  of 
too-fine   suture    material   which   cuts 


out  when  the  patient  vomits.  In 
bleeding  ulcer  of  the  stomach  it  is 
sometimes  extremely  difficult  to 
recognize  all  of  the  bleeding  surface 
while  the  tissues  are  held  in  tension. 
Relaxation  of  tissues  and  pressure  on 
the  viscera  with  the  fingers  or  with 
gauze  may  start  a  free  bleeding  which 
localizes  the  ulcerated  area.  Post- 
operative ileus  may  develop,  which 
may  be  due  to  obstruction  from  adhe- 
sions, to  internal  strangulation,  or  to 
angulation  of  bowel,  particularly  in 
the  anterior  operation,  if  the  loop  is 
not  supported  by  side  sutures  in  the 
omentum. 

Aside  from  vomiting,  which  is 
symptomatic  of  this  obstruction,  we 
may  have  a  non-obstructive  type 
which  supervenes  at  a  late  period 
(one  or  two  months  following  opera- 
tion). The  nature  of  the  vomiting  is 
not  always  clear,  but,  since  operators 
have  sought  to  preserve  the  natural 
direction  of  the  jejunum,  cases  of 
obstruction  and  vomiting  have  been 
much  less  frequent. 

The  gastroenterostomies  done  at 
Kocher's  clinic  since  1898  amounted  to 
137,  of  which  92  were  for  non-malignant 
affections.  All  the  patients  have  gained 
considerably  in  weight,  except  the  10 
last  operated  on.  The  tendency  to 
vomit  also  passed  away,  except  in  one 
patient,  who  vomits  during  the  menses, 
and  another  patient,  with  nervous  com- 
plications. The  motor  functions  of  the 
stomach  return  to  normal  in  a  surpris- 
ing degree ;  the  hydrochloric  acid  is 
generally  reduced.  After  the  operation 
the  intestinal  functions  also  returned  to 
normal,  as  a  rule,  even  in  the.  cases  of 
old,  chronic,  obstinate  constipation. 
Pre-existing  dilatation  of  the  stomach 
generally  subsided  if  of  the  second  or 
third  degree,  but  that  of  the  first  de- 
gree did  not  seem  to  be  influenced  by 
the  operation.  In  12  cases  in  which 
the    gastroenterostomy    was    done    for 


ABDOMEN,    SURGERY   OF    (MORRIS). 


69 


carcinoma,  the  patients  snrvivcd  on  an 
average  nearly  eight  months.  Cilli 
(Mitt.  a.  d.  Grenz.  d.  Med.  u.  Chir.,  l>d. 
xviii,  Nu.  1,  1907). 

A  complication  of  considerable  grav- 
ity is  peptic  ulcer  of  the  jejunum,  at- 
tributed once  to  the  action  of  digestive 
enzymes,  but  now  regarded  as  having 
a  common  origin  with  ordinary  gastric 
and  duodenal  ulcer,  viz.,  hyperacidity 
(hyperchlorhydria)  and  toxic  injury  of 
terminal  arteries.  To  lessen  the  fre- 
quenc}^  of  this  complication  it  is  ad- 
visable that  every  patient  to  be 
operated  upon  be  first  treated  for 
hyperchlorhydria.  Peptic  ulcers  of  the 
jejunum  run  a  similar  course  to  that 
of  ulcers  higher  up,  terminating  at 
times  in  perforation. 

At  Feurer's  clinic  at  St.  Gallen,  there 
have  been  117  cases  of  gastroenteros- 
tomy. The  use  of  this  operation  for 
cancer  is  growing  constantly  less,  as 
the  conditions  are  much  better  after 
resection  of  the  pylorus.  The  mortality 
after  resection  has  been  only  16.66  per 
cent,  of  42  cases,  and  zero  in  the  last 
series  of  20,  while  that  of  the  gastro- 
enterostomies was  25.64  per  cent. 
Delaloye  (Deut.  Zeit.  f.  Chir.,  Bd. 
Ixxxiii,  Nu.  5-6,  1907). 

At  Hochenegg's  clinic  at  Vienna, 
there  were  56  cases  of  gastroenteros- 
tomy in  which  a  sufficient  interval  has 
elapsed  since  the  operation  to  judge  of 
the  permanent  results.  In  64  per  cent, 
the  patients  had  been  entirely  and  in 
24  per  cent,  almost  entirely  relieved  of 
all  disturbances  by  the  intervention. 
The  operation  not  only  put  an  end  to 
the  disturbances  from  the  stenosis,  but 
was  followed  by  the  healing  of  the 
ulcer.  Schulz  (Deut.  Zeit.  f.  Chir., 
June,  1907). 

Report  of  230  operations  on  the 
stomach,  112  of  which  were  for  malig- 
nant disease,  from  Schloffer's  clinic  at 
Innsbruck.  In  82.6  per  cent,  of  the  74 
cases  in  which  gastroenterostomy  was 
done  for  a  non-malignant  affection,  the 
patients  were  permanently  cured    (46) 


or  materially  improved  (11).  Of  the  16 
patients  with  cancer  treated  by  resec- 
tion, 4  arc  still  living,  1  after  three 
and  a  half  years;  t' e  average  survival 
was  from  two  to  nearly  three  years. 
Of  the  69  cancer  gastroenterostomies, 
4  patients  are  still  living,  over  a  year 
since  the  operation.  Kindl  (Beitrage 
z.  klin.   Chir.,   May,   1909). 

Condition  of  the  patient  one  year 
or  more  after  gastroenterostomy  in  175 
cases,  150  benign,  25  malignant: — 

Benign  Cases  (150). — The  immediate 
mortality  (death  within  thirty-five 
days)  was  10  per  cent.  Eighteen  died 
within  the  first  year  (12  per  cent.)  ;  22 
died  of  their  gastric  disorder  within 
five  years  (14.6  per  cent.).  Six  pa- 
tients are  alive,  but  have  been  operated 
vipon  within  one  year. 

Of  the  126  patients  who  survived  the 
operation,  and  have  been  under  obser- 
vation for  one  year  or  more,  81  (or 
nearly  two-thirds)  were  reported  as 
entirely  recovered,  or  well;  8  as  much 
better,  and  31  (nearly  1  in  4)  as  little 
or  no  better.  Of  the  150  patients,  89, 
or  60  per'  cent.,  were  much  better  or 
entirely  well ;  fully  30  per  cent,  died  or 
were  little  or  no  better  at  the  time 
of  report. 

Twenty-five  cancer  cases  are  re- 
ported, 20  being  in  men.  Ten  patients 
died  within  one  month  of  the  operation, 
an  immediate  mortality  of  40  per  cent. 
One  is  still  living,  two  years  after 
operation,  another  six  months,  and  an- 
other four  months.  Ten  patients  lived 
more  than  four  months  after  operation. 
Six  of  these  were  temporarily  much 
improved,  and  gains  of  weight  ranging 
from  eighteen  to  forty-seven  pounds 
are  recorded.  Two  patients  received 
no  benefit  at  all  from  the  operation. 
Bettmann  and  White  (Med.  Record, 
Oct.  9,  1909). 

Results  of  Roentgen  examination  of 
40  patients  from  a  few  months  to  six 
years  after  gastroenterostomy  to  de- 
termine its  ultimate  action.  The  author 
found  that  the  stomach  em.ptied  itself 
in  from  ten  to  twenty-five  minutes  in 
9  cases,  in  from  twenty  to  fifty  minutes 
in  15,  and  in  about  ninety  minutes  in  15. 
The    gastroenterostomy    thus    answered 


70 


ABDOMEN,    SURGERY    OF    (MORRIS). 


its  purpose  of  rapid  draining  away  the 
contents  of  the  stomach  in  nearly  every 
case,  and  this  effect  was  obtained 
whether  the  pylorus  had  previously  been 
permeable  or  not.  A.  Pers  (Ugeskrift 
for  Laeger,  Sept.  30,  1909). 

A  male  baby,  aged  6  weeks,  was  sub- 
mitted to  gastroenterostomy  for  con- 
genital stenosis  of  the  pylorus.  At  the 
age  of  5^  months  the  baby  weighed  12 
pounds  12  ounces,  having  gained  4 
pounds  since  operation.  The  figures 
indicate  that  the  digestion  and  absorp- 
tion of  the  fat  and  nitrogen  were  nor- 
mal in  this  baby  three  and  one-half 
months  after  the  operation,  and  they 
are  evidence  that  the  operation  of  gas- 
troenterostomy does  not  change  the 
powers  of  digestion  of  these  two  food 
components  and  agree  with  the  results 
published  by  the  writer  in  earlier  inves- 
tigations. Talbot  (Boston  Med.  and 
Surg.  Jour.,  April  14,  1910) . 

Fatal  postoperative  diarrhea  some- 
times occurs.  Its  nature  is  obscure 
and  seems  to  depend  upon  derange- 
ment of  bowel  function  due  to  shock 
to  the  sympathetic  ganglia. 

End-to-end  Anastomosis  after  En- 
terectomy. — This  may  be  efifected  by 
suture,  or  Murphy's  button.  The 
suture  methods  in  use  comprise  the 
simple  direct  suture,  the  combination 
of  suture  and  invagination,  the 
Connell  method,  etc. 

Simple  Suture. — The  mesentery  is 
first  united  by  transfixing  both  the 
cut  edge  of  the  gut  just  beside  the 
mesentery,  and  then  the  latter  close 
to  its  insertion.  The  same  through- 
and-through  suture  is  then  passed  in 
the  reverse  order  through  the  opposite 
mesentery  and  gut.  A  duplicate 
suture  is  now  passed  through  the 
other  side,  or  the  same  suture  may 
have  its  other  end  threaded  in  a 
needle  and  be  used  for  this  purpose. 
When  this  suture  is  tightened  the 
gap  in  the  mesentery  is  closed  with 


approximation  of  the  cut  ends.  The 
remaining  step  is  suture  of  the  latter, 
and  this  may  be  done  by  carrying  the 
original  two-tailed  mesenteric  suture 
from  its  knot  around  the  circum- 
ference of  the  gut  on  either  side  until 
most  of  the  circumference  has  been 
sutured.  The  opening  which  remains 
is  closed  with  an  outside  Lembert 
suture.  The  rent  in  the  mesentery  is 
closed  with  a  few  points  of  catgut. 

Maiinsell's  Method. — The  divided 
surfaces  of  intestine  are  placed  in 
rough  apposition  by  four  traction 
sutures  at  equidistant  points,  the  first 
at  the  mesenteric  insertion.  The 
next  step  is  to  introduce  a  pair  of 
forceps  through  the  intestinal  wall 
from  without  inward,  and  to  this  end 
a  slit  is  made  in  the  long  diameter  of 
the  bowel,  one  (either  side)  segment 
opposite  the  mesenteric  insertion  and 
about  one  and  one-half  inches  from 
the  cut  edge.  With  this  forceps 
the  loose  ends  of  the  traction  su- 
tures, previously  twisted  together,  are 
tightened  with  production  of  an  in- 
A'agination  of  the  distal  into  the 
proximate  segment,  the  two  serous 
coats  being  in  contact.  In  this  posi- 
tion the  two  edges  are  united  with 
a  chromicized-gut  suture  applied 
through-and-through,  the  traction  su- 
tures are  removed,  and  the  invagi- 
nated  segment  replaced.  An  external 
durable  Lembert  suture  is  now  ap- 
plied. 

Connell  Method. — As  in  the  preced- 
ing operation,  four  traction  sutures 
are  applied,  and  the  two  cut  edges  of 
intestine  are  sutured,  one-fourth  at  a 
time.  The  traction  sutures  which 
limit  each  quadrant  are  tightened  in 
turn,  and  the  intervening  intestine 
joined  by  applying  a  right-angled 
through-and-through  suture.    As  soon 


ABDOMEN,    SURGERY    OF    (MORRIS). 


71 


as  a  portion  of  the  gut  is  reunited 
one  of  the  tractors  becomes  unneces- 
sary and  is  removed.  At  the  close  of 
the  suturing  the  two  free  ends  are 
threaded  within  the  kunen  of  the 
intestine  upon  a  ligature  carrier, 
brought  outside  and  tied,  and  the 
knot  is  then  worked  back  on  the 
inside  of  the  gut. 

Murphy  Button. — Purse-string  su- 
tures are  applied  at  either  divided 
seg'hient  and  tightened  upon  the 
halves  of  the  button.  The  suture  for 
each  siae  is  a  two-tailed  one,  and 
first  transfixes  the  mesentery  at  its 
insertion.  The  tails  are  then  carried 
down  on  either  aspect  of  the  intes- 
tinal segment  to  the  point  opposite 
the  mesenteric  insertion,  the  suture 
of  chromicized  gut  being-  applied 
overhand.  The  tw^o  tails  of  the 
suture  having  been  tightened  upon 
the  halves  of  the  button,  these  are 
then  joined  and  locked.  The  rent  in 
the  mesentery  is  now  repaired  and  an 
outside  durable  Lembert  suture  ap- 
plied over  the  inside  suture.  Great 
care  is  taken  to  cover  the  bowel  inci- 
sion with  peritoneum  at  the  mesen- 
teric attachment. 

Lateral  Anastomosis. — In  this  oper- 
ation there  is  no  restoration  of  the 
continuity  originally  present,  but  a 
purely  artificial  opening  is  created 
between  the  two  segments  of  intes- 
tine. Such  an  operation  may  be 
termed  an  internal  enterostomy, 
wdiich  agrees  with  an  external  colos- 
tomy to  this  extent :  that  in  each  case 
a  fistulous  communication  is  set  up. 
In  this  connection  w^e  need  only 
describe  the  operations  of  entero- 
enteric  anastomosis  and  ileocolos- 
tomy,  for  the  gastroenteroanasto- 
moses  are  considered  elsewhere. 

This  anastomosis  may  be  effected 


in  se^'eral  ways — preferal^ly  by  su- 
ture, clamps,  elastic  ligature,  or 
Murphy's  button  may  be  desirable  in 
special  cases. 

Suture. — The  loop  of  intestine  is 
emptied  and  prevented  from  refilling 
by  finger  pressure,  clamps,  or  gauze 
loops.  Excision  having  been  per- 
formed, the  two  cut  ends  are  closed 
by  the  insertion  of  inverting  Lembert 
sutures,  the  slack  of  the  mesentery 
being  included  in  the  inversion.  A 
double  cul-dc-sac  thus  results,  the  two 
parts  of  which  are  to  be  joined  in  the 
resulting  lateral  anastomosis.  The 
two  ends  are  apposed  for  a  space  of 
four  inches  or  more,  and  a  single  line 
of  Lembert  sutures  applied  at  their 
junction.  The  segments  being  now 
in  their  permanent  position,  they  are 
incised  close  to  the  suture  line  with 
scissors.  As  a  rule,  the  length  of  the 
incisions  should  be  three  inches. 

A  continuous  suture  of  chromicized 
gut  is  carried  along  both  sides  of 
the  new  opening,  thus  constituting 
the  inside  suture  plane.  The  out- 
side plane  is  completed  by  a  second 
durable  Lembert  suture.  Of  mechani- 
cal aids,  Myrphy's  oblong  button  is 
the  best  for  general  use,  the  tech- 
nique being  akin  to  that  of  the  round 
button  for  end-to-end  anastomosis. 

When  making  an  intestinal  resection, 
a  lateral  anastomosis  with  a  Murphy- 
button  may  be  done  with  such  rapidity 
that  an  immediate  resection  may  safely 
be  accompHshed.  The  writer  uses  the 
Hartley  method  in  making  the  lateral 
anastomosis,  dropping  half  of  a  Murphy 
button  into  each  end  of  the  gut  which 
is  left  after  resection,  and,  after  closing 
the  ends  of  the  gut  by  the  Lilienthal 
method,  pushes  the  halves  of  the  but- 
ton together.  Lilienthal  simply  ties  ofif 
the  gut  with  twine  instead  of  turning 
in  or  sewing  up  the  end.  The  writer 
has  now  used  it  six  times  with  six  sue- 


72 


ABDOMEN,    SURGERY   OF    (MORRIS). 


cesses.  In  3  cases  of  strangulated 
hernia,  he  resected,  made  a  lateral  anas- 
tomosis with  the  Murphy  button  by  the 
Hartley  method,  tied  off  the  ends  of 
the  gut  with  fine  linen  or  silk  by  the 
Lilienthal  method,  cut  off  the  ends  of 
the  silk  short,  and  dropped  the  gut 
back,  closing  the  abdomen  without  a 
drain.  In  another  case  of  strangulated 
hernia  he  did  the  same,  except  that,  on 
account  of  the  evident  infection,  he  in- 
serted a  rubber  drain  down  to  the  closed 
peritoneum.  Wallace  (Amer.  Jour,  of 
Surg.,  Jan.,  1911). 


cially  multiple  ones),  and  malignant 

disease. 

Operative  exclusion  of  the  colon  is 
indicated  as  a  last  resort,  but  in  a  per- 
sonal case  it  gave  excellent  results, 
freeing  the  patient,  a  woman  of  28, 
from  intestinal  disturbances  of  several 
years'  standing,  probably  due  to  sagging 
of  the  colon  and  chronic  colitis.  The 
fistula  in  the  cecum  still  persists,  but 
causes  no  annoyance,  and  the  patient 
has  gained  20  pounds  in  the  two  years 
since.  Hirschel  (Beitrage  z.  klin.  Chir., 
Dec,  1909). 


Closed. 


Open. 


Oblong  Murphy  button. 


Enteroexclusion. — The  temporary 
operation  is  not  a  procedure  compara- 
tive to  enterectomy.  It  is  without 
some  of  the  dangers  of  the  radical 
operation,  and  may  be  performed 
rapidly.  The  operation  consists  in 
division  of  the  intestine  and  lateral 
enteroanastomosis,  or,  in  the  case  of 
the  colon,  enteroimplantation,  A  dis- 
eased portion  of  the  intestine  which 
would  otherwise  demand  extirpation 
is  then  excluded  from  the  intestine. 
If  the  distal  end  is  closed  the  opera- 
tion is  known  as  partial  or  unilateral 
exclusion;  but,  if  it  is  also  made 
the  subject  of  an  anastomosis,  the 
intervention  is  known  as  double  or 
complete  occlusion.  The  chief  indi- 
cations are  tuberculosis,  fistulae  (espe- 


Unilateral  Exclusion. — No  attempt 
is  made  to  close  the  excluded  loop  at 
its  lower  extremity,  which  is  just 
above  the  anastomosis,  as  there  is  no 
danger  of  stagnation  of  feces  in  this 
locality.  Technically  the  operation  is 
well  adapted  for  the  use  of  Murphy 
buttons.  No  details  need  be  given, 
as  these  are  identical  with  the  details 
of  anastomoses  after  excisions.  Its 
chief  use  is  in  emergency  cases. 

Bilateral  Exclusion. — Both  ends  of 
the  excluded  loop  are  closed,  and 
either  two  anastomoses  are  made  or 
one  end  only  is  anastomosed  while 
the  other  is  left  in  the  external 
wound.  AVhen  the  operation  has  been 
done  for  actual  intestinal  fistulse,  both 
ends  of  the  loop  may  be  closed,  as 


ABDOMEN,    SURGERY   OE    (MORRIS). 


73 


the  loop  will  then  be  drained  suffi- 
ciently through  the  hstulous  open- 
ings. If  exclusion  is  done  for 
carcinoma  it  is  better  to  leave  one 
end  of  the  loop  in  the  external  wound, 
for,  when  the  operation  has  been  done 
for  an}-  incurable  condition,  exclusion 
must  be  followed  sooner  or  later  by 
excision. 

Enterostomy,  Jejunostomy,  Ileos- 
tomy.— The  establishment  of  an  arti- 
ficial opening-  in  the  small  intestine  is 
not  necessarily  for  the  purpose  of 
establishing-  an  anus  contra  naturam, 
but  may  be  done  simply  for  relief  of 
distention  or,  like  gastrostomy,  for 
the  introduction  of  nutriment.  The 
only  condition  justifying  this  form  of 
intervention  is  an  absolutely  irre- 
mediable stricture  of  the  pylorus  with 
resulting-  starvation. 

The  operation  may  be  done  like  a 
gastrostomy,  using  a  tube  or  catheter. 
It  is  preferable,  however,  to  sacrifice 
the  integrity  of  the  intestine  by  divi- 
sion and  anastomosis,  leaving  a  cut 
end  in  the  external  wound.  The 
point  selected  is  in  the  jejunum,  about 
eight  inches  below  the  duodeno- 
jejunal angle.  The  intestine  is 
divided  at  this  point  and  the  central 
end  implanted  •  six  or  eight  inches 
farther  along  the  gut.  The  peripheral 
end  is  not  treated  like  the  stomach 
cone  in  gastrostomy,  i.e.,  it  is  passed 
out  of  the  external  incision,  beneath 
the  skin,  and  out  at  a  special  opening 
(see  Gastrostomy).  The  original 
wound  is  closed  plane  by  plane  while 
the  fistular  wound  is  sutured  to  the 
divided  intestine. 

The  writer,  in  an  investigation  of  all 
gastrojejunostomies  done  by  him  in  St. 
Mary's  Hospital  to  ascertain  whether 
jejunal  ulcer  had  followed,  found  that 
out    of    1141    gastrojejunostomies    715 


were  performed  for  duodenal  and  gas- 
tric ulcer,  167  for  carcinomatous  ob- 
struction of  the  pylorus,  and  259  in 
connection  with  partial  gastrectomy, 
most  of  which  were  for  cancer.  Not  a 
single  case  of  jejunal  ul'^er  had  de- 
veloped, nor  did  any  case  appear  at  the 
clinic  in  cases  operated  by  other  sur- 
geons. W.  J.  Mayo  (Surg.,  Gynec.  and 
Obstet.,  March,  1910). 

Case  operated  on  for  ulcer  of  the 
stomach  in  which  a  posterior  no-loop 
gastroenterostomy  has  been  performed. 
The  operation,  while  it  relieved  the 
original  symptoms,  caused  frequent 
vomiting  of  biliary  and  pancreatic 
fluids,  due  to  some  spur  or  kink  left 
after  the  anastomosis.  The  operation 
performed  for  the  relief  of  this  re- 
gurgitant vomiting  consisted  in  anas- 
tomosing the  ascending  or  ter:iinal  por- 
tion o^  the  duodenum — just  as  it  turns 
upward — to  the  jejunum.  It  is  not 
necessarily  tedious  or  difficult  and  has 
the  advantage  of  producing  drainage  of 
the  duodenum  directly  into  the  jejunum 
— a  safety  valve,  so  to  speak,  in  the 
operation  '  of  the  gastroenterostomy — 
which  can  be  done  either  at  the  time 
of  the  gastroenterostomy  operation  or 
later  if  needed.  Since  his  operation  in 
this  case,  the  writer  has  twice  operated 
on  the  cadaver,  and  had  no  difficulty  in 
pulling  a  loop  of  duodenum  through 
the  covering  perit  neum  and  making 
the  anastomosis.  The  operation  will  not 
have  to  be  done  very  often,  but  may  at 
times  be  of  marked  value.  P.  S.  Mon- 
cure  (Jour.  Amer.  Med,  Assoc,  March- 
18,  1911). 

Ileostomy  is  sometimes  performed 
for  establishing  an  artificial  anus, 
necessarily  in  cases  where  ileocolos- 
tomy  or  simple  colostomy  is  insuffi- 
cient for  drainage.  The  lowest  pos- 
sible part  of  the  ileum  is  selected,  the 
incision  being  made  one  and  one-half 
inches  above  Poupart's  ligament.  In 
this  operation-  it  is  not  necessary  to 
divide  the  intestine,  and  the  technique 
does  not  differ  from  that  of  ordinary 
colostomy. 


74 


ABDOMEN,    SURGERY    OF    (MORRIS). 


Report  of  68  cases  in  which  jejunos- 
tomy  has  been  performed  during  the 
last  ten  years.  The  technique  was  Eisel- 
berg's  adaptation  to  the  jejunum  of 
Witzel's  obHquely  imbedded  tube.  It 
is  a  simple  operation,  while  it  insures 
complete  continence  for  fluids,  and  the 
fistula  closes  spontaneously  when  its 
purpose  has  been  accomplished  and  the 
drain  holding  it  open  is  removed.  One 
of  its  great  advantages  is  that  the  pa- 
tient can  be  well  nourished  until  normal 
conditions  can  be  restored.  This  is 
particularly  important  in  case  of  ulcer. 
Lempp  (Archiv  fitr  klin.  Chir.,  Bd. 
Ixxvi,  Nu.  1-2,  1905). 

Report  of  25  operations  in  which 
jejunostomy  was  done  by  Garre  at 
Ivonigsberg.  The  operations  were  for 
cancer  in  20  cases,  and  for  ulcer  or  its 
complications  in  the  others.  One  pa- 
tient succumbed  to  hemorrhage  from  a 
hemorrhagic  ulcer,  another  to  peri- 
tonitic  complications  of  a  very  large 
cancer,  another  to  marasmus  from  car- 
cinomatosis peritonitis  with  ascites,  and 
another  with  cancer  to  pulmonary  em- 
bolism— a  total  mortality  of  4  out  of  25 
cases.  Loyal  (Beitrage  z.  klin.  Chir., 
von  Bruns,  Bd.  li,  Nu.  3,  1907). 

Jejunostomy  does  not  merit  the  dis- 
credit into  which  it  has  fallen,  in  the 
view  of  many  surgeons.  The  results 
are  good  when  a  simple  technique  is 
employed.  Preference  is  given  to  two 
methods  of  operation :  the  q,ne  pro- 
posed by  Drucbert,  in  which  a  canal  is 
made  leading  out  from  the  intestine  be- 
tween the  serous  and  the  muscular  coats 
of  the  intestine ;  the  'her  proposed  by 
Eiselberg  and  Witzel,  in  which  the  canal 
is  made  along  the  wall  of  the  intestine 
by  plicating  it  over  a  catheter  as  in  the 
similar  method  of  performing  a  gas- 
trostomy. The  chief  object  of  any 
method  is  to  obtain  an  opening  in  the 
bowel  which  will  be  continent.  It 
should  be  one  that  can  be  easily  and 
rapidly  made  and  one  that  may  be  only 
temporary.  More  complicated  opera- 
tions do  not  accomplish  more  than 
these  simple  ones,  and  are  not  toler- 
ated so  well  by  the  enfeebled  patients. 
Delore  and  Thevenot  (Archiv  gen.  d. 
chir.,  vol.  ii,  p.  237,  1908). 


SURGERY  OF  THE  APPEN- 
DIX.— The  appendix,  while  nomi- 
nally a  portion  of  the  colon,  is  subject 
to  peculiar  affections  which,  in  them- 
selves often  trivial,  are  prone  to  give 
rise  to  the  most  serious  surgical  com- 
plications. The  mere  removal  of  the 
appendix  makes  up  a  small  portion 
of  the  actual  surgery  of  this  organ, 
which  includes  the  surgical  manage- 
ment of  appendix-abscesses,  appen- 
dix-peritonitis, and  other  complica- 
tions. Hence  the  description  of 
appendectomy  as  a  typical  operation 
representing  the  surgery  of  the  organ 
is  a  small  part  of  the  subject,  and  re- 
quires elaboration  only  because  of  the 
different  complications  surrounding  the 
work. 

The  typical  operation  in  a  case  of 
early  infection,  or  in  fibroid  degener- 
ation of  the  appendix,  consists  in 
bringing  the  appendix  to  the  outside 
of  the  abdomen,  ligating  it  like  an 
artery  with  catgut  at  two  points,  one- 
fourth  inch  apart.  We  sever  the 
appendix  between  these  two  points  of 
ligation  and  carry  a  drop  of  95  per 
cent,  carbolic  acid  into  the  lumen  of 
each  stump.  The  scissors  or  knife 
with  which  the  severing  is  done  is  not 
used  again  at  the  operation,  because 
the  instrument  is  now  infected,  and  is 
to  be  put  aside  in  a  safe  place.  The 
carbolic  acid  has  sterilized  the  tissues 
with  which  it  has  come  in  contact 
instantly,  and  in  order  to  stop  any 
further  and  undesirable  action  we 
neutralize  the  carbolic  acid  with  a 
few  drops  of  alcohol  applied  with  a 
pledget  of  cotton. 

The  next  step  is  ligation  of  the 
mesappendix  with  catgut  at  as  many 
points  as  desirable  in  any  particular 
case.  In  some  cases  the  mesappendix 
allows  a  safe  ligation  with  a  single 


ABDOMEN,   SURGERY   OF    (MORRIS). 


75 


lig^aturc.  In  other  cases  where  it  has 
a  particularly  broad  attachment,  four 
or  five  ligatures  may  be  required.  It 
is  quite  as  important  in  ligating'  mes- 
appendix  as  in  ligating  broad  liga- 
ment after  an  operation  for  ovariot- 
omy, not  to  include  too  much  tissue 
in  any  one  ligature,  and  not  to  cut 
the  stumps  too  short  above  the  lig'a- 
ture,  for  the  reason  that  vomiting  and 
other  movements  subsequent  to  the 
operation  are  particularly  apt  to  force 
off  these  ligatures  and  give  rise  to 
secondary  hemorrhage  or  opening  of 
the  lumen  of  the  appendix.  The  last 
step  after  cutting  away  the  mesap- 
pendix  consists  in  scarifying  the 
peritoneum  of  the  cecum  near  the 
stump  of  the  appendix  that  is  left, 
with  the  point  of  a  needle,  in  order  to 
insure  an  abundance  of  lymph  exuda- 
tion which  W'ill  wall  in  the  stump. 

The  author  has  employed  practi- 
cally all  of  the  fanciful  methods  of 
treatment  of  the  stump  which  have 
been  described  by  authors,  and  has 
dropped  all  but  this  simple  method, 
which  saves  time.  At  one  hospital 
where  four  thousand  appendectomies 
performed  by  this  method  have  been 
tabulated,  there  were  only  two  cases 
of  trouble  due  to  the  form  of  pro- 
cedure, and  both  of  these  were  due  to 
the  slipping  of  a  ligature,  both  liga- 
tures having  been  tied  by  the  same 
member  of  the  house  staff,  who  may 
not  have  learned  to  tie  square  knots, 
or  who  may  have  cut  stumps  too 
short.  Where  old  adhesions  make  it 
difficult  to  bring  the  appendix  out 
upon  the  abdominal  wall,  this  simple 
method  of  treatment  of  the  stump 
does  away  with  many  difficulties. 

In  cases  of  acute  infection  with 
abscess,  with  dense  new  or  old  adhe- 
sions,  it  is   extremely  unwise  to   at- 


tempt to  bring  the  cecum  to  the 
surface  in  order  to  carry  out  peculiar 
methods  of  treatment  of  the  stump  of 
the  appendix,  and  in  such  cases  it  will 
suffice  if  we  snap  a  pair  of  forceps 
upon  the  appendix  close  to  the  cecum, 
and  remove  the  appendix  with  the 
finger  without  further  detail,  unless 
one  wishes  to  leave  another  pair  of 
forceps  on  the  mesappendix.  The 
forceps  left  in  place  for  twenty-four 
hours  serve  to  protect  also  the  small 
drain  placed  alongside.  At  the  end 
of  twenty-four  hours  the  forceps  may 
be  removed,  and  no  more  attention 
given  to  the  stump  of  the  appen- 
dix. In  these  far-advanced  cases  the 
arteries  of  the  mesappendix  have 
commonly  been  occluded  by  pro- 
liferating endarteritis  and  the  veins 
are  filled  with  thrombi,  so  that  the 
hemorrhage  amounts  to  nothing  more 
than  a  moderate  degree  of  oozing 
cared  for  by  the  capillary  drain. 
Such  simple  treatment  does  away 
with  a  great  part  of  the  dangerously 
severe  part  of  operative  work  which 
in  the  third  era  of  surgery  has  often 
been  thought  necessary.  Treatment 
of  abscesses  and  peritonitis  of  appen- 
dix origin  is  discussed  under  the 
general  head  elsewhere  in  the  article. 
See  also  Appendicostomy  and  the 
article  on  Appendicitis  in  the  second 
volume   of   this   work. 

Series  of  110  operations  showing  the 
advantage  of  simplicity  in  operating, 
with  mortality.  Nearly  one-half  of  the 
patients  were  under  15  years  of  age. 
Sixty-four  were  acute  cases,  the  pa- 
tients being  operated  upon  either  in 
the  interval  or  at  a  late  non-purulent 
stage.  In  44  acute  cases,  operation  was 
done  on  the  first,  second,  or  third  day. 
Two  patients  were  operated  upon  the 
fourth  day,  1  on  the  fifth,  1  on  the 
sixth,  4  in  the  seventh,  5  on  the  eighth, 
2  on  the  tenth,  1  on  the  eleventh,  3  on 


7(> 


ABDOMEN,   SURGERY   OF    (MORRIS). 


the  twelfth,  and  1  on  the  twenty-third 
day.  This  tends  to  show  that  the  risk 
of  operation  on  any  particular  day  is 
not  unduly  great.  The  writer  empha- 
sizes the  advantage  of  a  small  incision, 
the  quick  drainage  of  the  appendicular 
site  if  pus  is  there,  the  removal  of  the 
appendix  only  if  it  is  easily  reached, 
the  absolute  neglect  of  the  remainder 
of  the  peritoneal  cavity  except  as  it 
may  be  favorably  influenced  by  the 
drainage.  Dowd  (Annals  of  Surg., 
Oct.,  1909). 

The  writer  has  lost  no  patient  upon 
whom  he  operated  within  thirty-six 
hours  of  the  attack.  During  the  past 
five  years  he  has  had  nine  deaths  fol- 
lowing operations  performed  between 
the  second  and  eighth  days  of  the 
attack.  Only  one  of  these  deaths  oc- 
curred in  his  hospital  practice,  and 
others  were  all  after  operation  per- 
formed  at  the   homes   of  the   patients. 

When  a  patient  suffering  with  appen- 
dicitis of  more  than  forty-eight  hours' 
duration  cannot  safely  be  transported 
to  the  hospital,  he  should  be  put  on  the 
Ochsner  treatment  and  o^^eration  post- 
poned until  the  acute  inflammition  has 
subsided.  When  the  abdomen  has  fin- 
ally become  flat,  pain  and  tenderness 
have  disappeared,  and  the  pulse  and 
temperature  have  become  normal,  the 
appendix  may  be  safely  removed.  Col- 
'lins  (111.  Med.  Jour.,  Oct.,  1909). 

Chronic  appendicitis,  so-called,  is  not 
always  relieved  by  appendicectomy.  A 
Lane  kink  near  the  ileocecal  valve  may 
be  the  real  cause  of  obstruction  and 
simulate  the  above  condition.  The  main 
symptoms  as  described  by  Stierlin  are 
as  follows :  There  are  attacks  of  colic, 
mainly  located  in  the  region  of  the 
cecum  and  ascending  colon,  unaccom- 
panied by  any  rise  in  temperature,  and 
often  associated  with  continued  pain- 
ful sensations  in  this  region ;  the  pain 
may  also  involve  the  region  of  the 
stomach.  It  may  last  for  a  longer  or 
shorter  time.  Chronic  obstinate  con- 
stipation is  present,  alternating  with 
short  periods  of  diarrhea;  these  latter 
usually  occur  at  the  end  of  an  attack  of 
colic.  A  tumor  of  a  balloon-like  char- 
acter is  felt  in  the  region  of  the  cecum. 


which,  upon  palpation,  gives  forth 
gurgling  sounds,  and  which  may  or  may 
not  be  painful;  it  is  often  distinctly 
movable.  Hofmeister  (Beitr.  z.  klin. 
Chin,  Bd.  Ixxi,  Hft.  2,  1911). 

Colostomy. — Now  and  then  it  be- 
comes necessary  to  perform  colostomy 
for  patients  suffering  from  chronic  ob- 
struction induced  by  a  growth,  stric- 
ture, angulation,  adhesion,  volvulus, 
invagination,  foreign  body,  diver- 
ticulum, or  enteroptosis,  after  other 
measures  have  been  tried  and  failed. 
Again,  an  artificial  anus  is  sometimes 
made  to  relieve  patients  suffering  from 
membranous  catarrh,  the  various 
types  of  ulcerative  colitis  and  multi- 
ple polypi,  but  this  procedure  is  not 
so  popular  for  this  purpose  as  it  was 
before  the  advent  of  appendicostomy 
and  cecostomy. 

An  artificial  anus  should  never  be 
made  except  as  a  dernier  ressort  be- 
cause of  its  unnatural  location,  the 
odors  which  emanate  from  it,  the 
necessity  of  wearing  a  bandage,  and, 
further,  because  a  serious  operation 
is  required  when  the  time  for  its 
closure  arrives. 

An  artificial  anus  may  be  tem- 
porary when  made  as  a  preliminary 
step  to  excision  and  resection  or  until 
such  time  as  the  condition,  for  the 
relief  of  which  it  was  made,  has  been 
cured;  or  permanent,  when  the  open- 
ing is  to  remain  through  life. 

It  is  not  necessary  to  spend  as 
much  time  in  the  formation  of  a  tem- 
porary anus  as  it  is  in  the  making  of 
a  permanent  anus,  because  the  former 
is  to  be  of  short  duration  and  the 
patient  can  bear  the  annoyance  for  a 
short  time.  In  permanent  colostomy 
it  is  of  the  utmost  importance  to  pro- 
vide for  the  patient's  comfort  by 
making  the  opening  in  such  a  way 


ABDOMEN,   SURGERY   OF    (MORRIS). 


71 


that  he  may  not  ha\'e  painful  evacua- 
tions, complete  fecal  incontinence  or 
procidentia. 

Formerly  there  was  considerable 
discussion  as  to  which  was  the  better 
procedure,  inguinal  or  lumbar  colos- 
tomy ;  but  lately  the  latter  has  fallen 
completely  into  disuse  because  the 
operation  is  more  difficult,  a  suitable 
spur  cannot  be  made,  and  the  anus  is 
situated  where  the  patient  cannot 
easily  attend  to  it,  while  the  former 
operation  is  devoid  of  all  of  these  dis- 
advantages. 

Except  where  there  are  special 
reasons  for  doing  otherwise,  the 
colonic  aperture  should  be  made  of 
fair  size  and  as  low  down  in  the 
bowel  as  possible,  because  here  the 
feces  are  more  solid  and  give  less 
trouble  than  when  the  anus  is  estab- 
lished at  or  near  the  cecum.  An  anal 
opening  should  never  be  made  in  the 
small  bowel  because,  when  this  is 
done  there  is  a  constant  discharge  of 
fluid  through  it,  which  annoys  the 
patient  and  keeps  the  skin  continually 
excoriated. 

The  majority  of  surgeons  concen- 
trate their  efforts  toward  the  forma- 
tion of  a  proper  spur  and  the  produc- 
tion of  the  double-barrel-gun  effect, 
to  prevent  any  of  the  feces  from 
reaching  the  rectum,  but  do  compara- 
tively little  toward  providing  an  anus 
over  which  the  patient  can  exert  a 
fair  degree  of  control. 

The  Murphy  button  is  a  suitable  and 
proper  instrument  for  the  establishment 
of  an  anastomosis  in  the  large  intestine. 
The  danger  that  the  anastomosis  with 
the  button  will  not  be  efficient  when 
proper  technique  is  used  in  connection 
with  a  good  button  is  no  greater  than 
when  anastomosis  is  made  by  means  of 
sutures.  The  chief  danger  from  the 
button  lies  in  the  arrest  of  the  button 


by  means  of  dried  fecal  matter  or  a 
foreign  body,  as  a  cherry  or  plum  stone. 
In  the  after-treatment  it  should  be  seen 
that  the  bowels  are  emptied  at  proper 
intervals.  At  the  first  indication  of 
obstruction  of  the  bowels  the  anas- 
tomosis should  be  examined.  The 
Murphy  button  in  the  large  intestine 
affords  the  easy  technique  and  the 
brevity  of  the  operation  it  does  else- 
where. Miihsam  (Dcut.  Zeit.  f.  Chir., 
Bd.  105,  Hft.  3-4,  1910). 

Report  of  19  cases  of  primary  re- 
section of  the  large  intestine  at  von 
Eiselberg's  clinic  at  Vienna.  Three  of 
the  patients  did  not  survive  the  opera- 
tion ;  one  of  this  group  had  had  a 
febrile  sore  throat  a  short  time  before, 
and  the  fatal  peritonitis  was  due  ex- 
clusively to  streptococci.  The  operation 
should  have  been  postponed  to  allow 
time  for  the  streptococcus  infection  to 
die  out.  In  another  similar  case,  al- 
though the  patient  recovered,  yet  strep- 
tococcus peritonitis  followed  the  angina 
and  streptococci  could  be  cultivated 
from  the  .blood.  In  the  third  case  the 
patient  was  doing  well  up  to  the  fifth 
day  after  extensive  resection  of  stomach 
and  intestine,  but  then  a  suture  on  the 
ascending  colon  gave  way.  In  all  the 
other  cases  the  wound  healed  by  pri- 
mary intention.  Haberer  (Archiv  f. 
klin.  Chir.,  Bd.  xciv,  Nu.  4,  1911). 

G ant's  Colostomy. — The  sigmoid  is 
reached  and  isolated  through  a  two- 
inch  incision  which  crosses  a  line  ex- 
tending from  the  umbilicus  to  the  an- 
terior superior  spine  of  the  ilium,  at 
the  inner  border  of  the  oblique  mus- 
cles ;  working  outward,  the  transver- 
salis  is  separated  from  the  internal 
oblique  muscle.  Math  the  index  and 
middle  fingers,  for  about  one  and  one- 
half  inches.  The  fingers  are  then  forced 
upward  through  the  oblique  muscles 
and  then  over  the  external  oblique 
and  inward  to  the  incision,  separating 
the  subcutaneous  fat  from  the  muscle. 
A  loop  of  the  sigmoid  is  now  hooked 
up    and   then    made   to   traverse   the 


7^ 


ABDOMEN,    SURGERY    OF    (MORRIS). 


route  taken  by  the  fingers,  which 
makes  it  pass  outward  between  the 
internal  oblique  and  the  transversalis 
muscles,  and  then  through  the  in- 
ternal and  external  obliques  and 
finally  over  the  latter  back  to  the 
incision.  Again,  when  it  is  sutured 
after, being  made  taut  to  avoid  the 
possibility  of  subsequent  procidentia, 
the  angles  of  the  wound  are  approxi- 
mated by  two  chromicized  catgut 
sutures,  which  pass  through  the  skin 
and  fascia  on  one  side  of  the  incision 
and  then  beneath  the  longitudinal 
band  of  the  sigmoid  and  out  through 
the  same  structures  on  the  other  side, 
where  they  are  tied.  After  the  gut 
has  been  attached  to  the  skin  by  a 
few  plain  catgut  sutures  it  is  sur- 
rounded by  a  bird's  nest  dressing 
to  prevent  its  being  pressed  upon, 
covered  with  rubber  tissue  lubricated 
with  sterile  vaselin  to  prevent  stick- 
ing of  the  gauze  to  the  bowel,  and 
then  the  outer  dressing  and  binder 
are  applied. 

The  intestine  is  not  opened  until 
after  the  third  day,  except  when  there 
is  a  marked  distention;  under  such 
circumstances  it  is  punctured  at  any 
time  after  six  hours  and  amputated 
later.  The  projecting  piece  of  gut  is 
quickly  and  painlessly  removed  by 
injecting  a  small  quantity  of  a  one- 
eighth  per  cent,  eucain  solution  into 
its  mesentery.  Cutting  of  the  bowel 
proper  causes  no  pain  and  does  not 
require  anesthetizing. 

By  a  few  cuts  of  the  scissors,  the 
intestine  is  amputated  about  one- 
quarter  of  an  inch  from  the  skin, 
bleeding  points  are  ligated  en-  masse, 
and  hemorrhage  from  oozing  surfaces 
is  controlled  by  hot-water  compresses 
or  the  cautery.  The  raw  edges  left 
are  encouraged  to  heal  rapidly  by  the 


occasional  application  of  6  p(n-  cent, 
silver  nitrate.  When  the  obstruction 
is  located  above  the  sigmoid,  the  steps 
in  the  operation  must  necessarily  be 
modified  to  meet  the  indications,  but 
the  changes  in  the  technique  will 
suggest  themselves  to  the  surgeon  in 
individual  cases. 

Patients  have  but  little  control 
over  an  artificial  anus  for  the  first 
few  days,  no  matter  what  operation 
is  performed,  because  the  soreness  of 
the  wound  and  the  irritability  of  the 
intestine  excite  frequent  and  strong 
peristalsis  and  the  involuntary  dis- 
charge of  the  feces. 

This  procedure  has  the  advantage 
over  other  colostomies  in  that  but  one 
incision  is  made  and,  further,  because 
it  gives  the  patient  a  more  perfect 
control  over  the  movements  than  do 
other  colostomies. 

According  to  Gant,  patients  oper- 
ated upon  in  this  way  except  during 
the  first  few  days  rarely  complain 
of  the  involuntary  escape  of  gas  and 
ordinarily  do  not  have  an  evacuation 
until  they  have  taken  a  mild  laxative 
or  stimulated  peristalsis  by  a  small 
enema. 

It  requires  very  little  time  to 
perform,  colostomy  for  a  patient  and 
the  operation  is  practically  devoid  of 
danger,  but  the  reverse  obtains  in  the 
operation  for  its  closure,  as  usually 
done  by  intestinal  anastomosis. 

To  avoid  the  dangers  which  accom- 
pany joining  of  the  two  ends  of  gut, 
Gant  has  devised  a  special  plan  for 
closing  artificial  ani.  Some  years  ago 
he  invented  a  clamp,  which  has 
proved  useful  in  the  closing  of  colos- 
tomy openings.  Its  weight  is  imper- 
ceptible to  the  patient,  and  when  in 
place  the  shank,  which  is  bent  at  an 
angle  to  the  clamp,  lies  flat  upon  the 


ABDOMEN,    SURGERY    OF    (MORRIS). 


79 


abdomen.  The  jaws  are  fenestrated, 
one-halt  inch  broad  and  one  and  one- 
fourth  inches  in  length.  It  is  applied 
as  follows :  The  clamp  is  placed  in 
the  applicator  forceps,  which  are  so 
adjusted  that  the  jaws  of  the  clamp 
remain  open  to  the  fullest  extent. 
The  parts  having  been  cleansed,  the 
partition  between  the  upper  and 
low^er  colostom}'-  openings  is  stripped 
to  dislodge  any  coil  of  the  intestine 
which    might    otherwise    be    injured. 


The  writer  describes  the  following 
method  calculated  to  insure  sphincteric 
control  after  colostomy;  The  rectus 
is  split  vertically  and  the  sigmoid  is 
drawn  out  and  divided  at  a  convenient 
point.  The  lower  segment  is  closed 
and  replaced  in  the  abdomen.  The 
upper  segment  is  made  less  bulky  by 
removing  the  appendices  epiploicse  and 
freeing  it  of  mesenteric  f-it,  but  with- 
out in  any  wa}'  interfering  with  its 
blood-supply.  The  artificial  sphincter 
is  then  made  in  the  following  manner: 
A    loop    of    muscle-fibers    is    separated 


Operation  for  sphincter  control  after  colostomy.     (Eyall.) 
(Clinical  Journal.) 


The  clamp  is  then  applied,  one  blade 
in  each  opening,  and  pushed  down 
sufficiently  to  inckide  the  entire  spur, 
when  it  is  released  from  the  instru- 
ment. It  is  allowed  to  remain  //;  situ 
until  the  spur  is  divided  and  it  comes 
away  unaided,  which  is  usually  from 
six  to  nine  days  later.  The  clamp 
causes  slight  soreness,  but  no  acute 
pain.  To  avoid  complications,  the 
patient  had  best  remain  quietly  in 
bed  until  it  sloughs  out.  AVhen  the 
partition  has  been  successfully  de- 
stroyed the  skin  and  edges  of  the 
opening  are  freshened  under  local 
anesthesia  and  closed  with  catgut  or 
silk,  and,  in  case  there  is  considerable 
tension,  the  wound  is  supported  by 
Avell-adjusted  adhesive  straps. 


from  the  posterior  aspect  of  the  rectus 
on  either  side  of  the  wound.  Each  loop 
is  then  drawn  over  to  the  opposite  side 
of  the  wound,  so  that  one  loop  over- 
laps the  other.  The  overlapping  loops 
thus  form  a  ring  and  through  this 
the  bowel  segment  is  drawn.  Sutures 
are  then  inserted  to  keep  the  muscle- 
fibers  together  above  and  bslow  wdiere 
the  bowel  comes  through.  Anchoring 
stitches  are  inserted  through  the  skin 
and  muscle  inside  to  keep  the  bowel  in 
position.  The  w^ound  is  then  closed 
above  and  below  the  bowel,  and  the  cut 
edges  of  the  latter  are  sutured  to  the 
skin.  A  double  sphincter  is  thus  formed 
consisting  of  longitudinal  and  circular 
fibers.  The  longitudinal  fibers  are 
those  of  the  anterior  portion  of  the 
rectus,  and  the  circular  fibers  are  formed 
by  the  loops  from  the  posterior  part  of 
the  rectus.  This  operation  can  be 
modified  by  making  double  loops  on 
each  side  and  making  them  overlap  one 


80 


ABDOMEN,    SURGERY    OF    (MORRIS). 


another  alternately.  A  similar  opera- 
tion can  be,  and  has  been,  carried 
through  the  external  oblique,  and  like- 
wise can  be  done  wherever  the  bowel 
is  brought  through  muscle.  A  some- 
what similar  operation  can  be  per- 
formed for  gastrostomy  and  appendicos- 
tomy.  C.  Ryall  (Clinical  Journal,  Xov. 
11,  1908). 

Lilienthal's  Colostomy. — The  for- 
mation of  an  artificial  anus  for  the  per- 
manent relief  of  obstruction  of  the 
lower  bowel  is  regarded  by  most  sur- 
geons as  a  loathsome  makeshift  for 
the  prolongation  of  life.  The  mental 
picture  of  such  an  opening  suggests  the 
constant  uncontrollable  discharge  of 
feces  and  flatus,  the  painful  and  an- 
noying dermatitis  in  the  neighborhood 
of  the  exposed  mucosa,  and  the  neces- 
sity for  constant  change  of  dressings — 
in  short,  a  condition  of  actual  and  per- 
manent disability  for  the  ordinary 
duties  and  pleasures  of  life. 

For  at  least  eight  years  Lilienthal  has 
been  performing  an  operation  which 
obviates  nearly  all  the  discomfort  and 
filthiness  of  colostomy.  The  patients 
have  absolute  control  of  the  bowels  and 
can  even  hold  a  considerable  quantity 
of  fluid  injected  into  the  colon.  The 
bowels  move  once  or  twice  a  day,  the 
patient  knows  when  the  movements  are 
about  to  occur,  and — not  by  any  means 
the  least  advantage — he  is  not  annoyed 
by  the  necessity  for  wearing  an  appli- 
ance for  obturation.  The  operation  has 
been  tested  many  times,  and  the  pa- 
tients have  been  for  the  most  part 
.  carefully  followed  up.  A  description 
of  the  steps  of  the  operation  follows : — 

An  incision  about  3^2  inches  long, 
more  or  less,  is  made  over  the  outer 
third  of  the  left  rectus  muscle  and  par- 
allel with  its  fibers.  The  upper  end  of 
this  incision  is  just  about  on  a  line  be- 
tween the   umbilicus   and   the   left  an- 


terior superior  iliac  spine,  but  the  exact 
length  and  location  of  the  wound  de- 
pends somewhat  on  the  amount  of  sub- 
cutaneous fat  present.  Through  this 
incision  the  fingers  explore  the  abdom- 
inal organs  and  the  type  and  limitations 
of  the  stricture  or  tumor  are  learned. 
The  sigmoid  flexure,  be  it  well  devel- 
oped or  not,  is  drawn  out.  As  is  well 
known,  this  part  of  the  intestine  varies 
greatly  in  length,  but  all  is  taken  out 
which  can.be  withdrawn  vrithout  ten- 
sion. The  two  legs  of  the  loop  are 
separated  as  widely  as  possible,  the 
upper  leg  being  sutured  to  the  perito- 
neum and  posterior  rectus  sheath  in  the 
upper  angle  of  the  wound,  and  the 
lower  is  sutured  in  a  similar  manner  to 
the  inferior  angle.  Silk  or  linen  thread 
is  the  suture  material,  and  the  stitch- 
ing is  done  by  the  continuous  method, 
every  third  stitch  being  tied  so  as  to 
avoid  purse-stringing.  The  mesosig- 
moid  is  now  sutured  through  and 
through  to  the  peritoneum  on  each  side 
(Fig.   1  in  the  annexed  plates). 

At  the  lower  leg  of  the  loop  the  gut 
is  doubly,  ligated  very  tightly  with 
heavy  silk  or  cotton  twine.  Section  is 
carefully  made  between  the  ligatures, 
taking  care  to  avoid  soiling  from  the 
small  amount  of  imprisoned  intestinal 
contents.  Pure  carbolic  acid  on  a  gauze 
sponge  is  used  to  sterilize  the  mucosa. 
Chain  ligatures  of  catgut  or  silk  are 
now  passed  through  the  mesosigmoid 
so  as  to  prevent  hemorrhage,  and  this 
membrane  is  then  cut  across.  We  now 
have  a  short  piece  of  sigmoid,  the  dis- 
tal leg  of  the  loop  in  the  lower  angle 
of  the  wound,  and  a  long  piece  sutured 
in  the  upper  angle  of  the  wound.  The 
remainder  of  the  mesosigmoid  is  cut 
away  from  the  long  piece  of  intestine, 
freeing  it  completely.  The  entire 
wound  is  now  protected  by  gauze  pack- 


The  Dotted  Line  Shows  Line  of  Section.    The  Blunt  Retractor 

Holds  Outer  Third  of  Rectus  Muscle  Together  with  Skin 

and  Aponeurosis.     {Howard  LUienthal.) 

Annals  of  Surgery. 


Redundant  Bowel  and  Mesocolon  Cut  Away.     Twisting  of  the 

Intestine  Begun.     {Howard  Lilienthal.) 

Annals  of  Surgery. 


Twist  Complete  and  Maintained  in  Position  by  Anchor  Sutures 

Holding  Sigmoid  to  Aponeurosis.     (Howard  Lilienthal.) 

Annals  of  Surgery. 


|r~ 


Operation  Complete.    Aponeurosis  Further  Stitched  to  Intestme 

and  Wound  Closed  with  the  Exception  of  the 

Skin.      (Howard  Lilienthal.) 

Annals  of  Surgery. 


ABDOMEN,   SURGERY   OF    (MORRIS). 


81 


ings,  the  peritoneum  by  our  previous 
procedures  being  entirely  closed  off 
by  suture.  We  should  have  about  3  or 
4  inches  of  free  sigmoid  at  the  upper 
angle  of  the  wound.  If  there  is  more 
it  should  be  ablated.  Four  equidistant 
clamps  are  now  placed  at  the  edge  of 
this  upper  piece  of  intestine ;  the  gloved 
finger  is  inserted  into  the  lumen  of  the 
gut  to  the  place  where  it  is  held  to 
the  peritoneum  by  suture ;  an  assistant 
rotates  the  clamps  so  as  to  twist  the 
gut  around  its  longitudinal  axis,  after 
the  manner  described  by  Gersuny, 
from  180  to  360  degrees  according  to 
the  texture  and  thickness  of  the  walls 
of  the  sigmoid  w'ith  which  we  are 
working.  By  withdrawing  and  rein- 
serting the  finger  from  time  to  time  the 
degree  of  constriction  which  this  ma- 
neuver produces  may  be  accurately 
gauged.  When  this  seems  to  be  suffi- 
cient for  the  purpose — a  matter  of  in- 
dividual judgment — a  few  interrupted 
silk  or  linen  sutures  passed  through 
the  visceral  peritoneum  and  submucosa 
to  the  aponeurosis  of  the  external 
oblique  hold  the  rotated  gut  in  posi- 
tion. It  is  now  necessary  to  make  sure 
by  re-examination  that  a  sufficient  twist 
has  been  accomplished.  If  this  seems 
satisfactory  more  sutures  should  be  put 
in  to  hold  the  gut  firmly  to  the  apo- 
neurosis. 

In  examining  with  the  finger  now 
w-e  find  a  double  sphincter,  the  first 
one  at  the  twist ;  the  second,  more  an 
angulation  than  a  sphincter,  at  the 
point  of  peritoneal  fixation.  A  few 
chromic  gut  sutures  close  the  portion 
of  the  remaining  wound  in  the  aponeu- 
rosis. The  sphincteric  action  is  main- 
tained by  the  fibers  of  the  rectus 
muscle  as  well  as  by  the  twist  in  the 
intestine.  A  large-sized,  rather  stiff- 
walled  rubber  rectal  tube,  not  a  woven 


one,  is  now^  inserted  about  six  inches 
into  the  intestine  and  is  tied  in  place,  a 
single  light  suture  passing  through  its 
walls  guarding  against  its  accidental 
extrusion.  The  remainder  of  the 
w^ound  is  left  open  and  packed  with 
gauze  while  the  tube  is  led  off  into  a 
receptacle  at  the  side  of  the  bed.  These 
wounds  always  become  more  or  less 
infected,  but  I  have  encountered  a  true 
phlegmon  only  once  and  then  a  single 
incision  sufficed  for  its  drainage. 

About  a  week  after  the  operation  the 
tube  may  be  withdrawn  and  the  re- 
dundant sigmoid  burned  off  with  the 
actual  cautery.  Anesthesia  is  not  nec- 
essary. Even  then  it  will  be  found  that 
repeated  cauterizations  will  be  required 
during  the  course  of  the  healing  in 
order  to  bring  the  intestinal  mucosa  to 
the  skin  level.  Daily  irrigations 
through  the  tube  should  be  practised  so 
as  to  keep  the  patient's  bowels  open. 
The  string  around  the  lower  piece  of 
intestine  should  be  removed  in  three  or 
four  days ;  otherwise,  there  might  be 
danger  of  complete  and  permanent 
closure,  and  it  is  necessary  to  main- 
tain patency  here  for  the  sake  of 
drainage. 

The  control  of  the  bowels  is  learned 
gradually  by  the  patient,  and  he  is  as- 
sisted by  a  constipating  diet  and,  for 
the  first  few  weeks,  small  doses  of 
deodorized  tincture  of  opium  and  of 
subgallate  of  bismuth,  20  grains  three 
to  five  times  a  day.  It  takes  about  a 
month  for  the  final  result  to  be  at- 
tained, but  the  functional  result  in  all 
uncomplicated  cases  will  be  found  per- 
fect. 

Appendicostomy  and  Cecostomy. — 
These  operations  are  useful  in  the 
treatment  of  disease  located  in  the 
colon,  but,  when  the  disturbance  lies 
within  the  small  bowel  or  involves  it 


1-6 


82 


ABDOMEN,    SURGERY    OF    (MORRIS). 


and  the  large  intestine,  Gant's  cecos- 
tomy,  which  provides  a  means  by 
which  the  treatment  can  be  directly 
applied  to  both,  should  be  substituted. 
It  is  frequently  impossible  to  deter- 
mine whether  the  disease  is  limited 
to  the  colon  or  not,  and  because  of 
this  and  the  fact  that  this  operation 
is  no  more  difficult  or  dangerous  than 
appendicostomy  and  ordinary  cecos- 
tomy,  and  is  equally  effective  both 
when  the  lesions  are  located  in  the 
small  intestine,  the  large  bowel  or 
both,  Gant  believes  his  to  be  the  most 
desirable  procedure  and  that  event- 
ually it  will  be  employed  almost,  if 
not  quite,  to  the  exclusion  of  appendi- 
costomy and  cecostomy  in  the  direct 
treatment  of  intestinal  affections. 

Appendicostomy. — Some  surgeons 
do  not  open  the  appendix  during  the 
operation  because  they  fear  infection. 
This  practice,  Gant  believes,  is  bad 
except  when  it  is  obvious  that  the 
appendix  is  not  obstructed,  because 
he  has  encountered  three  failures  fol- 
lowing it;  in  one  the  appendix  was 
too  short,  in  another  it  was  strictured, 
and  in  still  another  it  was  blocked  by 
an  encysted  grapeseed. 

He  immediately  amiputates  the  ap- 
pendix and  introduces  the  probe- 
pointed  appendiceal  irrigator,  then 
nothing  can  interfere  with  postoper- 
ative irrigation,  but  when  the  appen- 
dix is  diseased  .  it  is  removed  and 
cecostomy  is  performed.  It  is  impor- 
tant that  the  irrigations  be  started  at 
once  when  patients  suffering  from 
ulcerative  colitis  are  despondent, 
greatly  debilitated,  have  many  move- 
ments, lose  considerable  blood,  and 
suffer  from  insomnia  and  autointoxi- 
cation. 

To  meet  these  conditions  Gant  has 
devised  a  technique  for  appendicos- 


tomy which  provides  for  irrigation 
both  during  and  following  the  opera- 
tion, since  the  adoption  of  which  his 
patients  have  gained  very  much  more 
rapidly  than  formerly,  when  the  ap- 
pendix was  not  opened  for  several 
days,  during  which  time  nothing  was 
done  to  relieve  them.  Now  and  then 
a  stitch  abscess  has  occurred,  but 
other  complications  have  not  arisen 
during  or  following  the  operation. 
Briefly  described,  the  following  are 
the  steps:  1.  The  appendix  is  ap- 
proached through  a  gridiron  incision 
and  located  by  tracing  the  anterior 
longitudinal  band  downward,  when  it 
and  the  cecum  are  freed  and  brought 
outside.  2.  The  cecum  is  drawn  first 
to  one  side  and  then  the  other  by  an 
assistant,  while  the  parietal  perito- 
neum is  removed  at  the  sides  of  the 
incision  to  insure  union  between  it 
and  the  transversalis  fascia,  or  the 
peritoneum  is  left  intact  when  the 
gut  is  to  be  brought  into  contact  with 
it.  3.  The  appendix  is  freed  and 
straightened  by  ligating  and  dividing 
adhesions  and  the  mesentery  at  about 
one-fourth  inch  from  it.  4.  After  the 
cecum  has  been  scarified,  two  sero- 
muscular suspensory  sutures  are  in- 
troduced on  either  side  and  near  the 
base  of  the  appendix,  each  taking- 
three  bites  in  the  gut.  5.  By  means 
of  a  strong,  long-handled  needle,  the 
anchoring  stitches  are  in  turn  carried 
through  the  entire  thickness  of  the 
abdomen  and  clamped  with  forceps, 
but  when  the  intestine  is  joined 
directly  to  the  peritoneum  the  bowel 
is  anchored  by  chromicized  gut  su- 
tures, including  the  parietal  perito- 
neum and  transversalis  fascia.  6. 
Having  surrounded  the  appendix  with 
gauze,  a  traction  suture  is  introduced 
to  steady  it  while  it  is  being  ampu- 


ABDOMEN,   SURGERY   OF    (MORRIS). 


83 


tated,  cauterized,  and  prol:»ed.  7.  A 
Gant  appendiceal  irrigator  closed  with 
a  stopper  is  introduced  and  the  ap- 
pendix ligated  above  it.  8.  The  ap- 
pendix is  placed  in  the  lower  angle 
of  the  wound,  pointing-  upward  to 
prevent  leakage  later,  and  anchored 
by  two  seromuscular  chromicized-gut 
sutures,  which  include  the  trans- 
versalis  fascia.  9.  The  abdominal 
layers  are  then  separately  approxi- 
mated by  interrupted  or  continuous 
stitches,  after  which  the  cecal  sus- 
pensory sutures  are  tied  across  rubber 
tubes.  10.  The  appendiceal  irrigator 
is  prevented  from  slipping  out  by  the 
adjustment  of  adhesive  straps  or  by 
means  of  attached  pieces  of  tape 
which  encircle  the  body.  11.  In 
urgent  cases  from  one  to  three  pints 
of  a  warm  saline  solution  are  imme- 
diately injected  into  the  colon,  when 
the  stopper  is  introduced  to  prevent 
leakage.  12.  The  wound  is  sealed  by 
means  of  cotton  and  collodion,  and  is 
protected  further  by  split  gauze  pads 
which  overlap  each  other  when  placed 
about  the  appendix.  13.  The  outer 
end  of  the  irrigator  is  surrounded  by 
twisted  gauze  strips  to  prevent  pres- 
sure upon  it  when  the  outer  dressings 
composed  of  gauze  pads  or  cotton  and 
a  many-tailed  binder  are  adjusted. 

Appcndicocecostomy. — On  six  differ- 
ent occasions  Gant  has  been  com- 
pelled to  abandon  appendicostomy 
for  cecostomy  because  the  appendix 
was  too  short,  strictured,  or  blocked 
by  a  grapeseed  which  rendered  it 
unfit  for  irrigating  purposes  or  had 
sloughed  off  following  appendicos- 
tomy. In  each  instance,  after  the 
appendix  had  been  amputated  or 
inverted,  a  catheter  was  introduced 
through  the  appendiceal  stump  or 
opening    and    fastened    by    a    purse- 


string  suture  introduced  at  or  near  its 
Ijase.  The  cecum  was  suspended  and 
the  rest  of  the  operation  performed 
as  in  appendicostomy. 

Two  patients  suffered  from  diar- 
rhea induced  by  ulcerative  lesions  in 
the  colon.  In  these  cases  the  catheter 
was  introduced  a  short  way  into  the 
cecum,  providing  for  colonic  irriga- 
tion. 

The  others  were  afflicted  with 
enterocolitis,  and  it  was  thought  ad- 
visable to  irrigate  both  the  large  and 
small  intestines.  This  was  accom- 
plished by  guiding  a  catheter  across 
the  cecum  through  the  ileocecal  valve 
into  the  small  bowel.  This  procedure 
is   termed   "appcndicocecostomy." 

The  principal  objections  to  this 
operation  are  (1)  that  a  change  of 
catheters  is  impossible  because  the 
appendiceal  and  ileocecal  openings 
are  nearly  on  the  same  level,  and  (2) 
because  the  appendiceal  aperture  is 
so  small  that  two  catheters  of  suffi- 
cient size  cannot  be  introduced  to 
provide  for  large  and  small  bowel 
irrigation. 

Cecostomy. — Experience  has  dem- 
onstrated to  Gant's  satisfaction  that 
cecostomy  is  preferable  to  appendi- 
costomy in  the  direct  treating  of 
intestinal  disease.  A  comparative 
study  of  the  advantages  of  cecostomy 
and  the  disadvantages  of  appendicos- 
tomy, as  enumerated  below,  will  show 
why  the  former  should  take  prefer- 
ence over  the  latter. 

The  advantages  of  the  cecostomy 
operation,  and  more  especially  the 
writer's  cecostomy,  which  provides  a 
means  of  irrigating  both  the  large 
and  small  intestine,  are:  1.  Owing 
to  the  fact  that  the  cecum  lies  against 
the  inner  abdominal  parietes,  it  can 
be  easily  anchored  without  angulating 


84 


ABDOMEN,   SURGERY   OF    (MORRIS). 


or  twisting  the  bowel.  2.  Since  the 
opening  is  opposite  the  ileocecal 
valve,  a  catheter  can  be  introduced 
into  the  small  bowel  for  irrigating 
purposes  or  the  siphoning  of  its  con- 
tents for  examination.  3.  The  cecal 
opening  can  invariably  be  made  of  a 
suitable  size.  4.  The  circular,  valve- 
like projection  formed  around  the 
catheter  by  the  infolding  purse-string 
sutures  prevents  leakage.  5.  The 
catheter  can  be  changed  without  diffi- 
culty. 6.  Closure  of  the  opening  fol- 
lows withdrawal  of  the  catheter  and 
a  few  applications  of  the  copper  stick 
or  cautery.  7.  Owing  to  the  natural 
position  of  the  cecum,  there  is  less 
tension  and  pain  following  its  anchor- 
age to  the  abdomen  than  occurs  after 
appendicostomy.  8.  This  cecostomy 
may  be  employed  in  the  treatment  of 
lesions  located  anywhere  in  the  intes- 
tinal canal,  while  appendicostomy  is 
limited  to  those  in  the  colon. 

The  disadvantages  of  appendicos- 
tomy are  the  following:  1.  The  ap- 
pendix is  more  difficult  to  bring  up 
for  anchorage  than  the  cecum  because 
of  its  deeper  and  more  uncertain 
position,  and  because  it  is  frequently 
bound  down  by  adhesions  or  a  short 
mesentery.  2.  Anchoring  of  the  ap- 
pendix causes  angulation  or  twisting 
of  the  cecum,  which,  in  turn,  may 
induce  constipation,  discomfort,  or 
pain.  3.  When  the  cecum  about  the 
appendiceal  base  is  caught  in  the 
wound,  it  induces  nausea  and  vomit- 
ing until  detached  (writer's  case).  4. 
When  the  appendix  is  small,  short, 
strictured,  bound  down  by  adhesions, 
blocked,  or  is  otherwise  diseased,  it  is 
useless  for  irrigating  purposes.  5. 
Irrigation  is  frequently  difficult  and 
unsatisfactory  because  of  the  small 
appendiceal  opening.    6.  Pain  follow- 


ing appendicostomy  is  much  greater 
than  after  cecostomy  owing  to  the 
pulling  upon  the  appendix  by  the 
loaded  cecum,  the  periappendiceal 
adhesions,  or  the  squeezing  of  the 
attached  mesentery  when  the  wound 
is  closed  tightly  about  it.  7.  Fre- 
quent dilatation  or  the  insertion  of  a 
catheter  is  often  necessary  to  keep 
the  opening  sufficiently  large.  8. 
Death  has  followed  injection  of  the 
irrigating  fluid  into  the  abdomen 
beside  the  appendix  where  an  interne 
mistook  an  opening  in  the  wound  for 
that  of  the  appendix.  9.  After  a  cure 
it  is  more  difficult  to  close  the  ap- 
pendiceal than  the  cecal  outlet,  and 
frequently  appendectomy  is  impera- 
tive. 10.  Appendicostomy  frequently 
fails  because  the  appendix  slips  back 
into  the  abdomen  or  retracts  suffi- 
ciently to  make  irrigation  almost  or 
quite  impossible.  11.  The  appendix 
has  been  known  to  slough  off  on 
several  occasions  owing  to  tension,  its 
constriction  by  the  sutures  or  destruc- 
tion of  its  blood-supply  making  subse- 
quent cecostomy  necessary.  12.  Appen- 
dicostomy is  not  effective  when  the 
disease  is  located  in  the  small  intes- 
tine. 13.  Appendicitis  requiring  ap- 
pendectomy following  closure  of  the 
appendiceal  outlet  has  occurred.  14. 
Owing  to  the  irritation  caused  by  the 
catheter  or  treatment  the  mucosa  may 
become  so  inflamed  and  swollen, 
ulcerated  or  strictured,  that  irrigation 
must  be  abandoned.  15.  Finally,  ac- 
cording to  Reed,  the  catheter  causes 
the  wall  of  the  appendix  frequently 
to  perish  in  a  few  days. 

Cecostomy  zvitli  an  Arrangement  for 
Irrigating  both  the  Small  Intestine  and 
Colon. — Gant  has  described  what  he 
believes  to  be  an  original  way  of  irri- 
eatine  both  the  small  and  large  bowel 


Abdomen,  surgery  of  (morris). 


85 


through  the  same  opening  in  the 
cecum — an  operation  which,  for  want 
of  a  better  name,  lie  has  designated 
"cecostomy  with  an  arrangement  for 
irrigating  both  the  small  intestine 
and  colon." 

Pie  believes  his  cecostomy  is  su- 
perior because  the  technique  is 
simple,  the  operation  requires  no 
more  time  than  others,  there  is  less 
leakage  owing  to  tlie  purse-string 
infolding  being  substituted  for  his 
lateral  sutures,  both  the  small  and 
large  bowel  can  be  irrigated  by  the 
attendant  or  patient,  a  firmer  support 
is  obtained  by  attaching  the  cecum 
to  the  transversalis  fascia  than  to  the 
parietal  peritoneum,  and  the  opening 
heals  spontaneously  after  the  cathe- 
ters are  removed. 

Briefly  described,  the  steps  in 
Gant's  cecostomy  are:  1.  Through 
a  two-inch  intermuscular  incision 
made  directly  over  the  cecum,  it  and 
the  lowermost  part  of  the  ileum  are 
withdrawn  and  the  edges  of  the 
wound  covered  with  gauze  hand- 
kerchiefs. 2.  The  anterior  surface  of 
the  cecum  is  scarified  after  the  as- 
cending colon  and  ileum  have  been 
clamped  to  prevent  soiling  of  the 
wound  when  the  bowel  is  opened.  3. 
Four  linen  seromuscular  purse-string 
sutures  are  introduced  into  the  an- 
terior wall  of  the  cecum  opposite  the 
ileocecal  valve,  and  the  bowel  is 
opened  inside  the  suture  line.  4.  The 
gut  is  grasped  at  the  juncture  of  the 
large  and  small  intestines  and  held  in 
such  a  way  that  the  ileocecal  valve 
rests  betAveen  the  thumb  and  fingers 
of  the  left  hand.  A  Gant  catheter 
guide  is  then  passed  directly  across 
the  cecum  and  through  the  ileocecal 
valve  into  the  small  intestine,  aided 
by  the   thumb    and   fingers.      5.  The 


guide  is  held  by  an  assistant  while 
the  obturator  is  removed  and  a  cathe- 
ter is  introduced  into  the  small  bowel. 
It  is  then  removed  and  the  catheter 
firmly  held  in  the  small  gut  by  an 
assistant  until  anchored  to  the  cecum 
by  catgut  sutures  to  prevent  its  slip- 
ping out  during  the  operation.  6.  A 
short  rubber  tube  three  inches  long 
is  projected  into  the  cecum  for  an 
inch  or  more  and  anchored  beside  the 
one  in  the  small  gut.  7.  The  infold- 
ing- purse-string  sutures  are  now  tied, 
forming  a  cone-shaped  valve  above 
the  catheters  to  prevent  leakage  of 
gas  and  feces.  8.  After  removal  of 
the  clamps,  the  cecum  is  scarified  and 
anchored  to  the  transversalis  fascia, 
denuded  of  its  peritoneum  by  through- 
and-through  suspension  sutures  of 
linen,  or  by  chromicized  catgut 
stitches,  including  the  fascia,  when 
the  two  peritoneal  surfaces  are  to  be 
approximated.  9.  The  wound  is 
closed  by  the  layer  method  and  the 
catheters  are  fastened  by  stitching  or 
by  encircling  them  with  an  adhesive 
strip  to  hold  them  together,  and 
crossing  this  at  a  right  angle  with  a 
second  piece  of  plaster  placed  be- 
tween the  catheter  to  prevent  their 
slipping  out.  10.  The  ends  of  the 
catheters  are  closed  with  cravat 
clamps  to  prevent  leakage,  and  the 
operation  is  completed  by  applying 
the  dressings  above  the  projecting 
tubes. 

One  catheter  is  left  longer  than  the 
other  or  is  identified  in  some  way  in 
order  that  the  interne  or  nurse  may 
know  zvhich  is  in  the  large  and  zvJiich 
in  the  small  intestine  when  time  for 
irrigation  arrives.  To  avoid  danger 
from  infection  treatment  is  not  begun 
before  the  fifth  day  except  when 
urgent. 


ABDOMEN,   SURGERY   OF    (MORRIS). 


The  catheter  may  be  readily 
changed  by  cutting  the  attached  ad- 
hesive strips  and  withdrawing  the 
one  projecting  into  the  cecum.  Gant's 
catheter  guide  is  then  passed  over 
the  other  into  the  small  intestine, 
where  it  is  retained  until  the  old  tube 
has  been  removed  and  a  new  one  in- 
troduced. A  second  piece  of  catheter 
is  then  placed  in  the  cecum  and  both 
are  prevented  from  slipping  out  by 
adjusting  fresh  adhesive  straps  after 
the  manner  already  described. 

Before  deciding  upon  the  above 
technique  Gant  irrigated  the  small 
intestine  by  passing  a  glass  or  silver 
catheter  through  a  cecal  opening,  past 
the  ileocecal  valve,  into  the  small  gut 
each  time  it  was  irrigated,  but  this 
practice  was  abandoned  as  impracti- 
cable because  of  the  difficulty  en- 
countered in  locating  and  passing  the 
valve,  and,  further,  because  the 
patient  could  not  irrigate  himself  in 
this  way. 

Gant  has  had  no  reason  to  suspect 
that  peristalsis  forced  the  catheter 
out  of  the  small  intestine  into  the 
cecum  except  in  one  of  his  first 
cecostomies,  where  the  tube  was  cut 
short  and  projected  only  one  inch 
beyond  the  ileocecal  valve  instead  of 
several,  as  it  should.  He  feels  confi- 
dent that  the  catheter  remained  in 
the  small  gut  in  his  other  cases  be- 
cause (a)  water  injected  through  the 
colonic  pipe  was  evacuated  much 
quicker  than  when  it  was  deposited 
in  the  small  bowel;  (&)  when  a 
minute  quantity  of  a  10  per  cent, 
solution  of  methylene-blue  was  in- 
jected through  the  former,  it  appeared 
in  the  urine  more  quickly  than  when 
introduced  through  the  catheter  in 
the  small  gut,  and  (c)  the  catheter 
guide  could  be  carried  over  the  tube 


in  the  small  intestine  and  the  latter 
could  be  removed  and  replaced  with 
a  new  one  at  will,  and,  further,  (d) 
fluid  feces  could  be  withdrawn  more 
quickly  and  frequently  through  the 
pipe  in  the  small  intestine  than 
through  the  colonic  catheter. 

To  avoid  possible  expulsion  of  the 
catheter  from  the  ileum,  catheters 
made  of  silk,  silver,  glass,  and  soft 
rubber  reinforced  by  an  inner  metal 
tubing  which  cannot  be  forced  out  of 
the  bowel  owing  to  their  non-flexi- 
bility are  employed.  Only  that 
portion  of  the  latter  projecting  into 
the  small  bowel  was  reinforced,  and 
as  a  result  it  served  the  desired  pur- 
pose and  caused  but  little  irritation 
because  it  was  soft  and  flexible.  This 
cecostomy  permits  the  attendant  or 
the  patient  to  irrigate  the  small  and 
large  intestines  at  will,  and  the  fluid 
may  be  siphoned  or  allowed  to  escape 
through  the  anus  and  the  catheter 
can  be  changed  quickly  as  often  as  is 
necessary. 

Enterocolonic  Irrigator. — An  instru- 
ment successfully  employed  by  Gant 
several  times  in  the  direct  treatment 
of  intestinal  affections  involving  both 
the  large  and  small  intestines.  It  is 
made  both  of  rubber  and  metal,  and 
has  worked  exceedingly  well  in  the 
few  cases  in  which  it  has  been  used. 

When  it  is  in  position,  the  attached 
inflating  bag  lies  in  the  small  intes- 
tine at  or  near  the  ileocecal  valve,  and 
when  distended  prevents  the  escape 
of  the  solution  into  the  cecum,  there- 
by enabling  the  attendant  to  accu- 
rately gauge  the  amount  of  fluid 
deposited  in  the  small  bowel  and  to 
retain  it  there  as  long  as  required. 
By  means  of  this  twin-tube  irrigator, 
the  small  and  large  intestines  can  be 
quickly     and     scientifically     flushed. 


AUDOMEN,    SURGERY   OF    (MORRIS). 


a; 


singly  or  tog-ether,  by  the  physician, 
nurse,  or  patient. 

The  steps  in  cecostomy,  when  the 
irrigator  is  employed,  are  similar  to 
those  already  described  when  separate 
catheters  are  used,  except  that  the 
Gant  catheter  guide  is  unnecessary 
and  the  apparatus  is  retained  in  posi- 
tion l\v  attached  pieces  of  tape  which 
encircle  the  body. 

Indications  for  Direct  Bowel  Treat- 
nieiit. — This  form  of  treatment  has  a 
much  wider  field  of  usefulness  than 
the  profession  at  present  realizes. 
]\Iost  physicians  and  surgeons  who 
have  practised  it  at  all  appear  to 
labor  under  the  impression  that  it  is 
limited  to  the  colon  and  is  indicated 
only  in  ulcerative  lesions  of  the  large 
bowel   causing  diarrhea. 

Gant  has  called  attention  to  the 
fact  that  this  type  of  cecostomy  is 
indicated  in  the  treatment  of  intesti- 
nal parasites,  enteritis,  enterocolitis, 
and  catarrhal,  tuberculous,  syphilitic, 
dysenteric  and  gonorrheal  colitis ; 
ordinary  and  pernicious  anemia ;  the 
many  manifestations  dependent  upon 
intestinal  autointoxication,  ptomain 
poisoning,  diarrhea  of  adults  and 
children,  intestinal  feeding,  malnutri- 
tion, and  following  operations  upon 
the  mouth,  throat,  esophagus  or 
stomach ;  in  gastric  stricture,  ulcer, 
cancer  and  other  disturbances  where 
rest  of  the  organ  is  indicated.  Gant 
also  called  attention  to  the  fact  that 
by  means  of  his  cecostomy  various 
intestinal  diseases  could  be  investi- 
gated, and  that  the  procedure  could 
be  used  to  determine  the  amount  and 
nature  of  the  intestinal  juices  and  dis- 
charges, the  character  of  the  feces, 
the  action  of  salines  and  other  cathar- 
tics injected  directly  into  the  small 
and  large  bowel,  and  the  marked  im- 


mediate vasomotor  effect  following 
hot  and  cold  enteroclysis  and  many 
other  interesting  problems. 

The  writer  has  reported  several 
cases  successfully  treated  by  his  opera- 
tion. While  he  has  had  no  personal 
experience  with  it  in  the  treatment  of 
cholera  and  typhoid  fever,  he  believes 
that  it  is  indicated  and  in  the  future 
would  be  used  in  the  treatment  of  these 
and  nearly  if  not  all  other  non-ob- 
structing diseases  of  the  small  and 
large  bowel. 

Gant  has  also  pointed  out  the  use- 
fulness of  appendicostomy  and  cecos- 
tomy as  a  means  of  drainage  when 
the  cecum  or  other  part  of  the  colon 
was  excluded.  He  has  also  employed 
appendicostomy  and.  cecostomy  a 
number  of  times  when  operating  for 
mechanical  constipation  where  colitis 
was  a  complication,  and  also  in  the 
palliative  treatment  of  obstipation 
where  the  patient  declined  to  have 
the  cause  of  the  obstruction  removed 
and  yet  suffered  from  deplorable 
autointoxication  or  recurring  impac- 
tion. 

Gant  has  also  performed  cecostomy 
once  for  the  relief  of  septic  peritonitis, 
but  the  patient  was  almost  moribund 
and  the  operation  failed.  Reed  was 
more  fortunate  in  the  two  cases  in 
which  he  resorted  to  cecostomy. 
This  authority  has  also  recorded  a 
case  of  "defective  flora"  of  the  colon 
which  was  improved  by  the  injection 
of  the  needed  bacteria  through  a 
cecostomy  opening,  has  called  atten- 
tion to  its  usefulness  in  the  treatment 
of  intussusception,  and  emphasizes 
many  other  important  points  concern- 
ing  cecostomy   and    appendicostomy. 

Following  direct  treatment,  the 
condition  of  the  patient  becomes 
rapidly     better     and     manifestations 


ABDOMEN,   SURGERY   OF    (MORRIS). 


such  as  anemia  and  those  induced  by 
autointoxication  rapidly  disappear, 
and  in  cases  of  diarrhea  the  frequency 
of  the  stools  generally  diminishes  and 
the  amount  of  blood,  pus,  and  mucus 
passed  becomes  markedly  less. 

The  good  results  following  the 
irrigating  treatment  are  due  mainly 
to  the  mechanical  action  of  the  fluid 
in  cleansing  and  stimulating  the 
ulcers  and  removing  retained  toxins, 
and  not  to  its  temperature  or  chemical 
contents.  Solutions  should  always  be 
employed  at  the  bodily  temperature 
or  warmer  because  of  their  soothing 
effect  upon  the  irritated  bowel,  and 
not  cold  or  at  a  freezing  point,  as 
recommended  by  some  authors,  be- 
cause when  injected  ice  cold  they  excite 
enterospasm  and  cause  much  un- 
necessary suffering. 

Briefly  stated,  the  most  reliable, 
stimulating,  and  soothing  remedies  to 
employ  are  weak  solutions  of  boric 
acid,  quinine,  formalin,  Hydrastis, 
krameria  and  soda,  silver  nitrate,  and 
those  of  a  soothing  nature  are  kero- 
sene, liquid  paraffin  or  olive  oil,  ac- 
cording to  indications.  The  stimulat- 
ing solutions  are  used  stronger  when 
ulceration  is  extensive  and  the  oils 
warm  when  the  gut  is  irritable. 

Owing  to  our  recent  knowledge  of 
diseases  of  the  colon,  the  internists 
agree  that  the  treatment  of  these  dis- 
eases by  medication  is  generally  un- 
satisfactory. The  great  length  of  the 
intestinal  tract  and  the  many  chemical 
changes  taking  place  before  medica- 
ments reach  the  colon  are  the  two 
principal  reasons  why  cecectomy  or  ap- 
pendicostomy  should  be  practised.  The 
posterior  position  of  the  appendix  and 
the  necessity  for  rotating  the  colon 
about  half  way  on  its  axis,  the  "possible 
sloughing  of  the  appendix  are  the  chief 
reasons  why  cecostomy  should  be  done 
instead  of  appendicostomy.     The  tech- 


nique is  as  follows  :  A  gridiron  incision 
is  made,  the  cecum  brought  up  and  held 
by  rubber-covered  forceps,  and  a  suit- 
able point  selected  for  the  fistula. 

This  opening  preferably  should  be 
made  opposite  the  ileocecal  valve,  so 
that  irrigation  of  the  small  intestine 
can  be  done  as  easily  as  of  the  large 
intestine ;  2  or  3  purse-string  sutures  of 
linen  are  inserted,  and  a  small  opening 
made  in  the  bowel  with  scissors.  A 
No.  10  soft-rubber  catheter  is  in- 
serted into  the  bowel  for  a  distance  of 
about  four  inches;  the  sutures  are  tied, 
inverting  the  head  of  the  colon,  which 
produces  a  valve  at  the  point,  and  pre- 
vents leakage.  The  cecum  is  attached 
to  the  parietal  peritoneum  with  chromic 
catgut.  The  catheter  should  be  fas- 
tened to  the  abdominal  wall  by  one  silk 
suture.  The  diseases  which  most  fre- 
quently require  cecostomy  are  amebic 
dysentery,  tuberculosis,  hemorrhage,  ul- 
cerations, colitis,  chronic  catarrhal  coli- 
tis, and  syphilitic  colitis.  W.  M.  Beach 
(Penna.  Med.  Jour.,  March,  1911; 
Amer.  Jour,  of  Gastroenterology,  June, 
1911). 

Colectomy. — Excision  of  the  colon 
is  performed  for  malignant  disease, 
including  tuberculosis  and  gangrene, 
but  in  practice  the  operation,  like 
colostomy,  is  confined  to  cecectomy 
and  sigmoidectomy,  unless  the  morbid 
process  directly  involves  the  trans- 
verse colon,  where  the  hepatic  or 
splenic  flexure  is  usually  the  seat  of 
the  disease. 

Cecectomy. — This  operation,  while 
so  named,  is  by  no  means  limited  to 
the  cecum,  for  it  is  usually  necessary 
to  remove  either  the  ascending  colon 
or  a  portion  of  ileum  or  of  both  intes- 
tines together.  Hence  such  interven- 
tion may  be  termed  ileocolectomy, 
ascending  colectomy,  etc.,  according 
to  the  individual  case. 

The  incision  is  made  in  the  middle 
line,  unless  the  diagnosis  has  been 
made  so  well  that  the  operator  can 


ABDOMEN,    SURGERY    OF    (MORRIS). 


89 


incise  directly  over  the  growth.  As 
in  all  similar  cases,  the  gut  is  mobi- 
lized, brought  out  and  walled  off  with 
gauze,  while  it  is  emptied  and 
clamped  or  held  empty  by  assistants' 
fingers  or  tape.  The  technique  differs 
little  from  that  of  enterectomy  of  the 
small  bowel.  The  mesentery  is  tied 
oft'  and  then  divided,  the  large  bowel 
excised  and  the  operation  completed 
by  restoring  the  continuity  of  the 
intestine.  As  the  cecum  and  ap- 
pendix have  been  sacrificed,  it  is 
necessary  to  secure  an  anastomosis 
between  the  ileum  and  transverse  or 
descending  colon. 

An  end-to-end  anastomosis  is  hardly 
practicable  because  of  the  disparity 
in  size  between  the  small  and  large 
bowel.  Hence  a  lateral  anastomosis 
or  an  implantation  is  indicated,  which 
may  be  made  by  suture  or  button. 
The  technique  is  that  usually  pur- 
sued in  all  intestinal  anastomoses. 

Lateral  anastomoses  are  practi- 
cable when  the  ileum  is  to  be  united 
with  the  neighboring  ascending  colon. 

No  attempt  is  made  to  provide  for 
a  cecal  pouch  or  ileocecal  valve,  but 
the  two  ends  are  joined  after  the  cut 
end  of  the  colon  has  been  closed. 

It  is  sometimes  advisable  to  im- 
plant the  ileum  in  the  descending 
colon  or  sigmoid  flexure  (ileosigmoid- 
ostom}^).  This  would  be  necessary  if 
the   ascending  colon  were   sacrificed. 

The  general  tendency  is  to  regard 
total  resection  as  indicated  only  when 
all  other  methods  of  treatment  have 
failed.  The  writer  reports  a  case 
in  which  after  exposure  of  the  intus- 
susception which  involved  the  ileum 
about  a  hand's  breadth  from  the  cecum 
it  was  found  impossible  to  reduce  the 
invagination.  It  was  resected  and  the 
bowel  ends  united  by  circular  suture. 
The    patient    recovered    and    was    dis- 


charged one  month  after  the  operation. 
Three  months  later  the  patient  was 
again  examined  and  found  well,  and 
six  months  pregnant.  She  was  delivered 
successfully.  Leichenstern  found  that 
in  479  cases  of  invagination  spontaneous 
reduction  of  the  invagination  occurred 
in  15  cases ;  also  in  15.6  per  cent,  of  the 
cases  of  invagination  of  the  ileum, 
with  a  mortality  of  42.6  per  cent.  We 
cannot,  therefore,  rely  upon  this  method 
of  treatment.  The  writer  agrees  with 
Rydigier  in  the  following  conclusions 
on  the  treatment  of  intussusception : 
In  acute  invagination  operation  should 
be  performed  as  soon  as  possible  after 
properly  employed  non-operative  meas- 
ures have  been  tried  without  success. 
When  a  laparotomy  has  been  done,  dis- 
invagination  is  to  be  preferred  when  it 
can  be  carried  out  without  special  diffi- 
culty. If  the  intestinal  wall  at  any 
place  in  the  area  of  invagination  is 
suspicious,  a  strip  of  iodoform  gauze 
should  be  introduced  to  this  place 
or  the  affected  area  excluded  from 
the  abdominal  cavity.  Resection  of 
the  whole  invagination  is  indicated 
when  the  intestinal  wall  shows  marked 
changes  or  threatens  perforation.  The 
employment  of  an  artificial  anus,  or 
enteroanastomosis,  is  to  be  condemned. 
The  author  believes  that  in  ileocecal 
and  colon  invagination,  when  disin- 
vagination  has  been  difficult  and  the 
serous  surface  of  the  intussuscipiens  is 
intact,  the  intussusceptum  may  be  re- 
sected. In  case,  however,  the  invag- 
ination is  only  a  short  one,  a  total  re- 
section should  be  done,  because  of  the 
better  prospects  of  a  radical  cure,  al- 
though one  should  also  take  into 
account  the  general  condition  and  age 
of  the  patient.  If  very  short,  unless 
reduced  with  very  little  difficulty,  re- 
section is  to  be  preferred  to  all  other 
methods.  But  even  when  the  invag- 
ination is  easily  reduced,  a  secondary 
resection  must  be  kept  in  mind,  since 
it  is  the  only  sure  means  for  the  pre- 
vention of  a  recurrence.  Haagn  (Deut. 
Zeit.  f.  Chir.,  S.  142,  1911). 

Sigmoidectomy. — As    the    sigmoid 
flexure  is  a  favorite  seat  for  cancerous 


90 


ABDOMEN,    SURGERY    OF    (MORRIS). 


growths  it  is  often  necessary  to 
excise  this  portion  of  the  bowel.  In 
some  cases  no  attempt  is  made  to 
restore  the  continuity  of  the  bowel, 
but  the  operation  is  terminated  by 
forming  an  artificial  anus.  If,  how- 
ever, the  sigmoid  is  movable  and  the 
tumor  can  be  removed  cleanly,  an 
end-to-end  anastom.osis  may  be  made. 
Even  when  the  rectum  needs  removal 
with  the  sigmoid,  operators  have  pre- 
ferred to  draw  down  the  sound  intes- 
tine and  suture  it  to  the  anal  region. 
SURGICAL  AFFECTIONS  OF 
THE  PANCREAS.— These  comprise 
inflammation,  cancer,  cysts  and  cal- 
culi. There  are  no  typical  operations 
for  these  afifections,  or  upon  the  pan- 
creas and  its  duct  for  any  conditions. 

The  most  important  and  special  in- 
dications for  operative  interference  in 
morbid  states  of  the  pancreas  are :  1. 
Injuries  to  the  pancreas  from  stab  or 
bullet  wounds,  or  severe  contusions  in 
the  epigastric  region.  2.  Inflammations 
—  (o)  acute  hemorrhagic  pancreatitis; 
(&)  subacute  pancreatitis;  (c)  chronic 
pancreatitis.  3.  Pancreatic  cysts.  Mc- 
Reynolds  (Wash.  Med.  Annals,  May, 
1908). 

Acute  Pancreatitis. — In  this  condi- 
tion the  pancreatic  juice  escapes  into 
the  tissues  of  the  pancreas  and  into 
the  peritoneal  cavity,  and  the  effect 
of  its  irritating  influence  is  very  de- 
structive. The  reddish,  purulent 
fluid  in  the  vicinity  can  be  removed 
by  a  drain,  and  tense  parts  of  the 
pancreas  can  be  scarified  to  allow 
some  of  the  interstitial  exudates  of  the 
pancreas  to  drain  out.  Drainage  is 
essential  after  removing  tumors,  or 
after  an  injury  to  the  pancreas  in 
order  to  dispose  of  the  irritating  pan- 
creatic secretion. 

The  escape  of  pancreatic  secretion 
from  an  injured  gland  reduces  living 


fat  in  this  vicinity  into  its  fatty  acid 
and  glycerin,  due  to  a  ferment  in  the 
pancreatic  fluid.  The  glycerin  is 
absorbed  and  the  fatty  acid  which 
remains  makes  a  combination  with 
lime  salts,  with  the  effect  of  produc- 
ing small  areas  of  dull  white  at  points 
where  the  reaction  has  taken  place. 

Acute  pancreatitis  should  be  the 
occasion  for  prompt  abdominal  sec- 
tion for  the  severe  and  fulminating 
symptoms  usually  present,  and  emer- 
gency laparotomy  would  in  any  case 
be  required.  If  the  patients  have  not 
died  outright  of  collapse  or  peritoni- 
tis, the  fat  necrosis  or  some  other 
secondary  condition  will  demand 
operation. 

Report  on  diagnostic  value  of  Cam- 
midge  reaction  based  on  501-  examina- 
tions. Of  26  patients  who  were  shown 
to  have  pancreatitis,  only  9  (35  per 
cent.)  gave  a  positive  reaction,  and, 
even  of  these,  7,  in  one  or  more  of  the 
series  of  3  tests,  gave  negative  results. 
Of  the  74  sick  persons  without  pan- 
creatitis, 35  (47  per  cent.)  gave  one  or 
more  positive  reactions.  Of  the  207 
sick  persons  who,  in  all  probability,  had 
no  pancreatitis,  73  (35  per  cent.)  were 
positive.  Of  the  17  well  persons,  5  (30 
per  cent.)  were  positive.  Even  when 
the  most  elaborate  care  is  exercised  to 
follow  the  technique  of  Mr.  Cam- 
midge's  "C"  reaction,  in  the  most  uni- 
form manner,  if  knowledge  of  the  clin- 
ical histories  and  other  factors  of  the 
personal  equation  be  eliminated,  the  end 
results,  judged  by  Mr.  Cammidge's  own 
criteria,  must  be  considered,  as  a  means 
of  diagnosticating  disease  of  the  pan- 
creas, as  both  valueless  and  misleading. 
Wilson  (Surg.,  Gynec,  and  Obstet., 
Aug.,  1910). 

Report  on  diagnostic  value  of  Cam- 
midge  test  as  studied  in  dogs.  The 
Cammidge  test  is  of  little  value  in  es- 
tablishing the  diagnosis  of  acute  pan- 
creatitis in  dogs.  If  the  test  is  nega- 
tive, it  is  pretty  strong  evidence  against 
an  acute  pancreatitis.    It  is  of  even  less 


ABDOMEN,   SURGERY   OF    (MORRIS). 


91 


value  in  the  condition  of  chronic  pan- 
creatitis in  dogs  and  may  be  consistently 
absent,  even  in  extreme  grades  of  this 
disease.  A  positive  Cammidge  test  is 
not  infrequent  in  normal  dogs  and 
men.  The  Cammidge  test  is  almost 
constantly  present  in  chloroform  poison- 
ing in  dogs — a  condition  in  which  there 
is  cr.treme  liver  necrosis  and  cell  autol- 
ysis. It  may  be  present  in  cases  of 
pneumonia,  or  in  any  condition  where 
there  is  active  cell  destruction  and 
autolysis.  It  may  be  produced  experi- 
mentally almost  at  will  by  intraperi- 
toneal injections  of  hydrolytic  cleavage 
products.  These  split  products  may  be 
prepared  by  boiling  pneumonic  lung- 
tissue  (dog  or  man),  or  thymus,  for 
hours  with  dilute  acid,  neutralizing, 
filtering,  and  concentrating  to  a  clear 
fluid.  Whipple  Chaffee  and  Fisher 
(Johns  Hopkins  Hosp.  Bull,  Nov., 
1910). 

The  pancreas  may  be  reached  either 
above  or  below  the  stomach,  through 
a  second  incision  into  the  omentum 
or  mesocolon,  after  making  a  suitable 
external  incision.  A  counteropening 
through  the  lumbar  region  may  be 
necessary  for  drainage.  If  an  abscess 
is  still  intact  it  should  be  opened 
wherever  most  accessible.  The  in- 
frequency,  fatal  character,  and  opera- 
tive mortality  (chiefly  unavoidable) 
do  not  justify  us  in  devoting  much 
space  to  abscess  of  the  pancreas,  the 
treatment  of  which  largely  resolves 
itself  into  management  of  the  second- 
ary conditions  to  which  it  gives  rise. 
Shallow  incisions  followed  by  simple 
wick  drainage  carried  to  the  pancreas 
certainly  serve  to  remove  poisonous 
exudates  to  advantage  in  some  cases 
of  acute  pancreatitis,  and  even  the 
simple  use  of  wick  drains  without 
scarification  of  the  pancreas  is  some- 
times followed  by  good  results.  We 
must  leave  room  when  draining  to 
allow  necrotic  masses  to  escape. 


In  acute  hemorrhagic  pancreatitis  the 
gravity  of  the  affection  is  due  to  the 
necrotic  destruction  of  the  pancreas 
rather  than  to  the  hemorrhage.  Chronic 
pancreatitis  consecutive  to  gall-stones  is 
a  well-individualized  morbid  entity,  and 
the  cure  after  effectual  drainage  of  the 
bile  passages  proves  its  dependence  on 
the  lithiasis.  The  operation  is  more 
successful  the  earlier  it  is  done,  before 
glycosuria  reveals  disturbance  in  the 
internal  secretion.  Cappelli  (Policlin- 
ico,  Aug.,  1909,  Surg.  Sect.). 

Cancer. — A  radical  operation  for 
cancer  of  the  pancreas  is  hardly  to 
be  considered,  and  the  only  palliative 
procedure  recognized  is  done  for  the 
relief  of  obstruction  of  the  intestine 
or  bile-tract. 

Cysts. — As  a  rule  these  can  only  be 
dealt  with  by  incision  and  drainage. 
In  a  few  cases  small  encysted  collec- 
tions of  fluid  affecting  only  a  portion 
of  the  organ_  have  been  excised  out- 
right. In  a  few  other  cases  cysts 
have  first  been  opened  and  drained 
and  then  excised  as  a  subsequent 
stage  of  procedure. 

Report  of  16  operated  cases:  2  of 
pancreatic  cyst,  1  of  pancreatic  car- 
cinoma, 3  of  acute  purulent  and  5  of 
chronic  pancreatitis,  and  5  of  hemor- 
rhages into  the  pancreas.  The  writer 
cautions  against  exploratory  punctures 
for  diagnostic  purposes,  and  emphasizes 
the  impossibility  of  differentiating  be- 
tween pancreatitic  cancer  and  chronic 
pancreatitis.  Necrosis  of  the  pancreas 
may  be  the  result  of  inflammation  or 
hemorrhage,  while  fat  necrosis  is  due 
to  the  escape  of  pancreatic  secretion 
into  the  intra-acinous  structures,  this 
occurring  most  frequently  after  hemor- 
rhage, and  less  often  after  pancreatitis. 
Of  the  5  cases  in  which  operation  was 
done  for  hemorrhage,  1  recovered  be- 
cause the  condition  was  recognized 
early  and  surgical  intervention  was 
promptly  resorted  to.  Bode  (Beitrage 
z.  klin.  Chir.,  Bd.  Ixxi,  Hft.  3,  1911). 


92 


ABDOMEN,    SURGERY    OF    (MORRIS). 


Calculi. — When,  as  occasionally 
happens,  the  pancreatic  duct  is  ob- 
structed by  a  calculus  the  condition 
cannot  be  diagnosticated  readily,  but 
is  recognized  when  operating  for 
some  other  condition,  usually  for 
gall-stones.  A  pancreatic  calculus 
may  sometimes  be  distinguished  from 
a  gall-stone  with  the  fluoroscope. 
The  indication  is  then  the  same  as  in 
obstruction  of  the  common  duct. 

One  of  the  few  surgeons  who  have 
discussed  typical  pancreatic  opera- 
tions is  Villan,  but  it  is  not  easy  to 
determine  what,  if  any,  portion  of  the 
work  he  describes  has  been  done  on 
the  living  human  being.  For  those 
interested  we  append  a  synopsis  of 
his  work. 

Villan  considers  the  surgical  man- 
agement of  pancreatic  diseases  as  well 
as  the  typical  operations,  but  it  is 
doubtful  if  any  of  the  latter  have  at- 
tained sufficient  dignity  to  be  thus 
regarded. 

The  term  pancreatotomy  is  applied 
to  incision  of  any  portion  of  the  organ 
or  its  surrounding  tissues,  for  any 
purpose.  If  followed  by  suture  it  is 
termed  pancreatorrhaphy.  Pancrea- 
tostomy  or  fistulation  of  the  pancreas 
is  simply  pancreatotomy  with  drain- 
age, and  is  a  frequent  procedure  in 
the  surgical  treatment  of  cysts, 
abscesses,  etc.  Pancreatectomy,  par- 
tial or  total  excision,  is  used  chiefly 
in  tumors  of  the  organ  (and  in  trau- 
matisms and  connection).  These 
operations  will  be  considered  else- 
where in  detail.  Pancreaticotomy, 
pancreaticostomy,  and  pancreatic  an- 
astomoses will  also  be  considered  in 
detail. 

Pancreatectomy. — This  is  neces- 
sarily partial.  It  has  been  done  only 
to  the  extent  of  excising  tumors.  The 


tumor  must  first  be  freed  from  any 
attachment  to  neighboring  organs  as 
well  as  from  the  pancreas  itself.  The 
excision  of  the  tail  of  the  pancreas  is 
attended  with  much  less  danger.  The 
tumors  here  are  more  likely  to  be 
pedunculated.  IMedian  laparotomy  is 
followed  by  liberation  of  the  tumor, 
traction  and  application  of  strong 
forceps  or  ligatures,  which  prevent 
the  entry  of  blood  and  pancreatic 
juice  into  the  peritoneal  cavity.  The 
pedicle  is  then  divided  and  cut  and 
sutured,  peritoneum  sutured,  and 
wound  closed.  It  is  often  prudent  to 
tampon  and  drain.  Excision  of  the 
head  of  the  pancreas  is  difficult  and 
dangerous.  Either  a  part  or  the 
whole  may  require  removal.  The 
tumor  is  detached  with  scissors  and 
bleeding  vessels  ligated.  The  ducts 
of  Wirsung  and  Santorini  should  be 
left  intact,  although  the  preservation 
of  either  one  will  suffice. 

If  Wirsung's  duct  should  be 
divided  it  is  usually  sutured,  and  the 
same  is  true  of  the  common  bile-duct 
should  it  be  injured,  although  at- 
mospheric pressure  will  sometimes 
serve  to  restore  continuity  of  wound 
margins  well  enough.  The  operation 
is  finished  by  suturing  the  remains  of 
the  pancreas  to  the  duodenum. 

If  the  entire  head  of  the  pancreas 
is  to  be  extirpated,  it  is  necessary 
first  to  ligate  the  pancreatic  duodenal 
artery  and  the  right  gastroepiploic. 
The  duodenum  must  not  be  separated 
from  the  superior  mesenteric  artery. 
Wirsung's  duct  and  the  common  duct 
must  be  kept  intact  when  possible; 
otherwise  they  must  be  preserved  by 
anastomosis. 

The  entire  pancreas  can  hardly  be 
excised  as  a  routine  procedure,  al- 
though  the    operation   may   be    sue- 


ABDOMEN,   SURGERY   OF    (MORRIS). 


93 


cessfully  performed  on  animals  and 
even  man.  It  is  followed  by  diabetes 
mellitus. 

Case  of  resection  of  part  of  the  pan- 
creas ;  approximately  two-thirds  of  the 
gland  was  replaced  by  the  tumor.  The 
results  of  the  experimental  work  done 
by  Halsted,  Flexner,  Opie,  and  Coffey 
in  this  country,  and  abroad  by  Pawlow, 
Biondi,  Desjardins,  Robson,  and  a  host 
of  others,  may  be  simmied  up  as  fol- 
lows :  Total  pancreatectomy  is  followed 
in  a  short  time  by  the  death  of  the 
animal.  Partial  pancreatectomy,  on  the 
other  hand,  permits  of  an  indefinite 
existence,  compensatory  regeneration 
and  hypertrophy  not  infrequently  taking 
place. 

In  properl}'  selected  cases  and  under 
favorable  conditions,  followed  by  care- 
ful protection  of  the  field  of  operation 
by  peritoneum  and  provision  for  the 
escape  of  the  pancreatic  secretion  by 
ample  gauze  drainage,  operations  in- 
volving resection  and  suture  of  the 
pancreas  were  followed  by  surprisingly 
good  results.  J.  M.  T.  Finney  (Annals 
of  Surg.,  June,   1910). 

Pancreaticotomy. — This  operation 
consists  in  incising  the  pancreatic 
duct  for  calculi.  The  duct,  as  in 
the  corresponding  operation  on  the 
common  bile-duct,  may  be  approached 
directly  or  through  the  duodenum. 

Simple  Pancrcaticotomy.-^Aiter  lap- 
arotomy and  exploration,  if  a  cal- 
culus is  found  therein,  the  canal  is 
incised,  and  the  concrements  remoA^ed 
by  forceps  or  other  apparatus  de- 
signed for  the  purpose.  Suturing  of 
the  cut  duct  is  not  necessary.  A 
fistula  naturally  remains  (pancreati- 
costomy),  but  has  a  tendency  to  close 
spontaneously. 

Transduodenal  Pancreaticotomy.  — 
The  duodenum  is  lifted  upward.  In- 
cision should  be  made  in  the  anterior 
portion,  and  while  some  surgeons 
advocate  a  transverse,  others  prefer 


a  horizontal  incision.  The  ampulla 
of  Vater  should  now  be  located,  and 
if  a  pancreatic  stone  is  present  the 
opening  may  be  incised  in  order  to 
extract  it.  Suture  of  the  incision  is 
not  necessary. 

Cathetering  of  the  pancreatic  duct 
and  crushing  of  large  calculi  are 
recent  procedures  in  connection  with 
this  operation. 

Pancreaticostomy  and  pancreatico- 
enterostomy  have  been  done  very  ex- 
tensively in  animal  experiment.  In 
human  surgery,  incision  of  the  pan- 
creatic duct  with  drainage  has  been 
practised,  but  the  operation  of  pan- 
creaticoenterostomy,  which  conserves 
the  pancreatic  juice  in  the  intestine, 
is  much  more  rational,  and  in  several 
instances  anastomoses  have  been  ef- 
fected between  the  canal  of  Wirsung 
and  some  part  of  the  digestive  tract. 

The  pancreaticoduodenal  region  is 
exposed  as  for  pancreaticotomy. 
Sutures  or  Murphy's  button  may  be 
used.  The  dilated  duct  should  be 
freed  from  adhesions  and  either 
grafted  into  the  intestine  or,  what  is 
preferable,  a  lateral  anastomosis  may 
be  made.  Pancreatic  fluid  coming  in 
contact  with  the  other  tissues  may 
cause  local  or  distant  necroses. 

SURGICAL    AFFECTIONS    OF 

THE  SPLEEN.— Abscess.— Splenic 
and  perisplenic  abscess  will  in  all 
likelihood  end  fatally  unless  some 
imusual  path  is  taken  by  the  burrow- 
ing pus.  Incision  and  drainage  is  the 
usual  procedure,  but,  if  the  spleen  is 
freely  movable  or  readily  freed  from 
adhesions,  splenectomy  may  be  the 
indication  of  choice. 

Cysts. — Simple  and  parasitic  cysts 
of  the  spleen  are  best  treated  by  inci- 
sion and  drainagfe  in  the  same  wav  as 


94 


ABDOMEN,    SURGERY   OF    (MORRIS). 


we  treat  abscesses.  If  the  spleen  is 
not  bound  down  by  adhesions,  the 
operation  may  be  done  more  safely 
as  a  two-stage  procedure,  the  first  of 
which  consists  in  suturing  the  cyst 
Avail  to  the  abdominal  parietes  with- 
out opening  of  the  former,  and  wait- 
ing for  forty-eight  hours  for  the 
formation  of  protecting  adhesions. 

Splenomegaly. —  Enlarged  spleen 
from  whatever  cause  is  usually  left  to 
medical  resources,  unless  it  becomes 
so  large  as  to  cause  serious  pressure 
symptoms,  in  which  case  removal  of 
the  spleen  may  become  a  necessity. 

Floating  Spleen. — AVhile  spleno- 
pexy has  been  sometimes  done  for 
this  condition,  most  operators  prefer 
the  more  radical  removal  of  the 
spleen  because  of  the  difficulty  of 
holding  this  organ  with  sutures,  due 
to  its  friable  tissues.  The  spleen  may 
be  iixed  through  an  incision  made 
obliquely  along  the  left  costal  margin 
to  the  C|uadratus  lumborum  muscle. 
The  patient  is  placed  in  the  abdominal 
position  upon  a  pad  or  air  cushion 
similar  to  that  used  for  forcing  the 
kidneys  against  the  abdominal  wall. 
The  peritoneal  surface  of  the  spleen 
is  scarified,  and  so  is  the  correspond- 
ing peritoneum  of  the  abdominal 
wall.  Kangaroo-tendon  interrupted 
sutures  entered  at  the  lowest  margin 
of  the  spleen  serve  to  fasten  it  nearly 
in  normal  position,  and  a  packing  of 
gauze  with  a  protecting  apron  of  gutta- 
percha tissue .  gives  support  until 
supporting  adhesions  have  formed. 
Rydygier,  for  fixing  the  spleen,  makes 
an  incision  in  the  middle  line  of  the 
abdomen  high  up,  and  forms  a  pocket 
in  the  parietal  peritoneum  through  a 
transverse  peritoneal  incision,  and  then 
with  the  fingers  forms  a  pouch,  into 
which  the   lower   half   of   the    spleen 


fits.  The  spleen  is  secured  in  this 
pouch  by  a  few  points  of  suture. 

Neoplasms. — Solid  tumors  of  all 
kinds  and  tuberculosis  require  early 
removal  of  the  spleen. 

TYPICAL  OPERATION  OF 
THE  SPLEEN.— Splenectomy.— The 
typical  external  incision  is  median 
in  traumatic  cases  (not  considered 
here),  but  in  all  others  either  the 
semilunar  line  or  one  following  the 
costal  arch  at  a  distance  of  an  inch 
or  so  gives  better  access  to  the 
pedicle.  The  next  stage  is  purely 
exploratory  and  involves  division  of 
peritoneum  and  examination  for  ad- 
hesions. If  there  are  no  diaphrag- 
matic or  pancreatic  adhesions,  it  is 
usually  possible  to  isolate  the  organ, 
although  extensive  ligation  may  be 
required.  It  is  sometimes  necessary 
to  free  the  spleen  from  the  pancreas 
by  sacrificing  a  portion  of  the  latter. 
The  organ  is  then  lifted  out  of  the 
wound,  and  packed  about  with  gauze. 
It  must  be  remembered  that  the 
spleen  is  very  easily  wounded  before 
it  can  be  ligated  oft",  and  that  profuse 
parenchymatous  oozing  will  then 
delay  the  operation.  As  in  other 
operations  on  abdominal  viscera, 
traction  on  the  pedicle  may  induce 
shock,  because  of  the  intimate  con- 
nection with  the  solar  plexus. 

The  next  stage  consists  in  ligating 
the  spleen  vessels,  which  is  accom- 
plished by  tying  off  the  splenorenal 
ligaments  and  gastrosplenic  omentum 
and  ligation  of  the  A^essels  of  the 
hilum.  The  latter  is  naturally  the 
ideal  choice,  but  the  delay  involved 
adds  to  the  dangers  of  shock,  and 
unless  the  patient  is  in  sound  condi- 
tion to  withstand  operation  it  may  be 
advisable  to  transfix  the  pedicle  in 
one   or   two   planes    according   to   its 


ABDOMEN,    SURGERY    OF    (MORRIS). 


95 


width,  and  ligate  each  l)y  ilscU'.  It 
is  well  til  luiN'e  apparatus  ready  for 
intra \eni>us  infusion,  which  may  l)e 
begun  at  any  moment  that  danger 
from  hemorrhage  appears. 

The  after-treatment  calls  for  no 
special  principles.  When  the  danger 
from  hemorrhage  or  sepsis  appears  to 
be  slight,  the  external  wound  may  be 
closed  at  once. 

The  position  of  the  patient  during 
operation  is  important.  A  large  sand- 
bag should  be  placed  under  the  back, 
under  the  upper  end  of  the  spleen, 
and  the  foot  of  the  table  lowered 
about  six  inches.  The  incision  may- 
be median  or  through  the  left  rectus 
muscle,  preferably  the  latter.  Tt 
should  be  ample,  and,  if  necessary,  a 
transverse  incision  may  be  made  from 
the  upper  end  of  the  primary  wound 
parallel  to  and  half  an  inch  below  the 
lower  border  of  the  ribs. 

The  splenophrenic  ligament  should 
be  first  attacked.  The  operator, 
covering  the  spleen  with  gauze, 
draws  it  to  the  right,  while  an  assist- 
ant draws  the  left  lip  of  the  wound 
to  the  left.  Where  possible,  the 
splenic  ligaments  and  all  vascular  ad- 
hesions should  be  doubly  ligated  in 
sections  and  cut  between  the  liga- 
tures; but  when  this  is  difficult  the 
ligaments  may  all  be  clamped  and 
the  blood-supply  entirely  cut  off  in 
this  way.  The  spleen  may  then  be 
removed  and  the  clamps  afterward 
sewed  round  and  removed  as  in 
oophorectomy.  In  difficult  cases  with 
extensive  adhesions  it  is  possible  to 
grasp  all  the  gastrosplenic  ligament 
between  the  index  and  middle  fingers 
of  the  left  hand  and  to  apply  a  long, 
curved,  rubber-covered  clamp.  After 
securing  this  ligament  fir^t,  the  other 
ligaments  may  then  be  clamped  or 
ligated  and  cut,  after  which  adhesions 
may  be  rapidly  separated  and  the 
bleeding  controlled  by  gauze  packing. 
Carr  (New  York  Med.  Jour.,  Feb.  16, 
1907). 

When  a  spleen  is  removed  in  a  case 
in  which  there  is  not  a  splenic  leukemia 


of  advanced  character,  the  operation  is 
f|uite  as  safe  as  is  the  one  for  removal 
of  the  thyroid  or  of  the  uterus  or  any 
other  simple  operation,  provided  that 
the  same  systematic  plan  is  followed. 
There  should  be  no  severe  traction  on 
the  pedicle  of  the  spleen  or  great 
manipulation  of  the  veins,  because  they 
are  exceedingly  friable.  After  sever- 
ing the  pedicle  below,  care  should  be 
taken  to  protect  the  smaller  veins  which 
often  enter  the  spleen  from  above.  If 
one  is  careless,  one  will  find  that  some 
of  the  large  veins  which  pass  through 
the  accessory  ligament  aie  exceedingly 
troublesome,  but  when  these  things  are 
looked  after  in  patieuts  not  suffering 
from  splenic  leukemia  the  operation  is 
a  safe  one.  The  author  has  had  one 
of  these  patients  go  through  a  severe 
pneumonia  afterward  under  the  care  of 
one  of  our  best  internists,  who  found 
no  difference  whatever  in  the  course  of 
the  disease.  If  the  leucocytosis  is 
higher  than  50,000,  then  one  can  count 
on  a  fatal  hemorrhage  after  the  splenec- 
tomy. The  writer  states  that  his  ex- 
perience in  15  or  20  cases  is  not  suffi- 
cient to  be  of  any  value  except  as  a 
guide.  If  there  is  leucocytosis  accom- 
panied by  a  rise  in  temperature,  then, 
of  course,  there  is  no  occasion  for  the 
operation,  because  one  would  no  more 
operate  in  this  chronic  condition  while 
there  is  an  acute  infectious  condition 
present  than  for  any  other  chronic  sur- 
gical condition.  Therefore,  if  the  leu- 
cocytosis is  the  result  of  the  leukemia, 
one  must  be  guarded  in  the  operation, 
and  not  fear  hemorrhage  from  the  large 
vessels  at  all,  but  hemorrhage  from  the 
small  adhesions.  The  blood  will  con- 
tinue to  ooze  out.  Gauze  may  be 
sutured  over  the  surface,  and  the  blood 
will  ooze  out  of  the  stitch  holes.  It 
will  ooze  out,  no  matter  what  one  does 
in  these  cases  of  advanced  splenic  leu- 
kemia. A.  J.  Ochsner  (Jour.  Amer. 
Med.  Assoc,  Jan.  1.  1910). 

The  writer  usually  uses  an  incision 
through  the  left  semilunar  line,  carry- 
ing, if  necessary,  the  upper  end  along 
the  costal  margin  to  the  ensiform  car- 
tilage. He  has  not  found  Myer's  pro- 
cedure  of  cutting  the  costal   cartilage.^ 


96 


ABDOMEN,    SURGERY   OF    (MORRIS). 


necessary  as  yet,  but  in  some  cases  a 
left  transversal  incision  joining  the 
longitudinal  is  convenient.  In  advanced 
disease,  adhesions,  especially  to  the 
diaphragm,  are  occasionally  difficult  to 
separate  until  after  the  splenic  pedicle 
has  been  secured.  To  grasp  this  vas- 
cular pedicle  temporarily  in  rubber- 
covered  elastic  clamps  is  the  most  im- 
portant step  in  the  operation  if  the 
vessels  are  fairly  sound.  This  must  be 
very  carefully  done  on  account  of  the 
delicacy  of  the  splenic  veins.  To  grasp 
the  pedicle  securely  the  organ  should  be 
turned  over,  at  least  enough  to  grasp 
the  vessels  in  the  hand.  With  the 
fingers  and  blunt  dissection,  a  pass- 
age is  made  around  the  pedicle  and 
a  clamp  applied  and  tightened  enough 
to  control  the  circulation  until  the 
spleen  can  be  entirely  separated  and 
delivered  outside  the  wound.  If  ex- 
tirpation is  the  object  of  the  opera- 
tion the  pedicle  can  be  secured  at 
any  time  after  the  application  of  the 
elastic  clamp,  which  is  applied  as 
close  to  the  root  as  possible,  so  as  to 
leave  distal  to  it  ample  space  for 
ligation.  If  partial  resection  is  to  be 
done,  temporary  compression  of  the 
pedicle  seems  harmless  if  there  are  no 
gross  vessel-wall  changes,  and  after  the 
use  of  the  clamp  the  desired  amount 
can  be  resected  and  the  hemorrhage 
controlled  by  buttonhole  catgut  suturing 
with  a  round  needle,  as  in  liver  resec- 
tion. "It  has  been  shown  experimen- 
tally that  reduction  of  the  artificial 
supply  by  ligation  resiilts  in  atrophy  of 
the  spleen,  and,  so  long  as  the  veins  are 
left  intact,  necrosis  does  not  occur.  If 
the  splenic  artery  divides  in  the  hilum, 
ligation  of  branches  would  appear  to  be 
an  active  competitor  of  partial  splenec- 
tomy. We  have  not  found  the  marked 
alterations  in  the  walls  of  the  blood- 
vessels which  have  been  shown  to  be 
often  present  at  post  mortem,  and 
which  probably  represent  a  terminal 
condition."  W.  J.  Mayo  (Jour.  Amer. 
Med.  Assoc,  Jan.  1,   1910). 

Four  cases  of  splenectomy  upon 
malarial  spleens.  The  first  case  was 
operated  upon  four  and  a  half  hours 
after  rupture  of  the  enlarged  spleen  by 
injury.    The  patient  died  a  few  hours 


after  operation,  primarily  from  the 
hemorrhage  which  followed  the  rupture. 
The  remaining  3  cases  recovered  from 
the  operation  with  much  improved 
health,  and  have  remained  free  from 
the  malarial  paroxysms  to  which  they 
had  been  subject.  Statistics  of  this 
operation  show  that  in  24  cases  col- 
lected by  Bessel-Hagen  up  to  1890  the 
mortality  was  65  per  cent.,  while  in  64 
cases  operated  upon  in  the  following 
decade  it  was  25  per  cent.  Solieri 
(Archiv  ffir  klin.  Chir.,  Bd.  92,  Hft.  2, 
1910). 

SURGICAL  DISEASES  OF  THE 
LIVER  AND  BILIARY  PASS- 
AGES.— The  chief  occasion  for  sur- 
gical intervention  in  these  localities 
is  gall-stone  disease  and  its  numerous 
consequences,  for  the  relief  of  which 
t3'pical  operations  are  required.  Sur- 
gical affections  of  the  liver  proper, 
while  numerous,  are  less  frequent, 
and  for  the  most  part  are  relieved  by 
simple  general  procedures,  as  incision 
and  drainage. 

Abscess  of  the  Liver. — Here  may 
be  considered  abscess  of  the  liver 
proper,  and  suppurative  pericystitis. 
As  soon  as  the  diagnosis  is  made  the 
pus  should  be  drawn  off  with  an 
aspirating  apparatus,  and  most  sur- 
geons prefer  to  make  an  exploratory 
incision  for  this  purpose.  In  some 
cases  it  may  be  necessaiy  to  excise 
one  or  more  ribs  and  go  through  the 
pleura,  in  which  case  the  operation 
should  consist  of  two  stages  in  order 
to  allow  protective  adhesions  to  form. 
After  the  pus  has  been  removed  an 
incision  should  be  made  of  such 
character  as  to  insure  complete  drain- 
age, and  the  abscess  cavity  allowed 
to  close.  If  much  liver  tissue  has  to 
be  divided  to  expose  the  abscess 
cavity,  it  will  be  necessary  to  use  the 
cautery  for  hemostasis. 

Subphrenic  abscess  may  be  con- 
sidered here,  although  it  may  occur 


ABDOMEN,    SURGERY    OF    (MORRIS). 


97 


on  the  left  side  and  have  no  connec- 
tion with  the  liver.  The  ii^eneral 
principles  of  operation  here  are  the 
same  as  in  abscess  of  the  li\'er — ex- 
ploration, aspiration,  and  eventually 
incision  and  drainage.  It  may  be 
necessary  to  g"0  through  the  thoracic 
wall. 

Cysts  of  the  Liver. — Hydatids 
should  be  extirpated  if  possible,  the 
operation  amounting  to  hepatectomy, 
which  see.  So  radical  a  procedure  is 
seldom  carried  out,  and  the  usual  inter- 
vention, both  for  hydatids  and  non- 
parasitic cysts,  is  incision  and  drain- 
age, with  the  possibility  of  going 
through  the  thoracic  wall.  The  oper- 
ation may  be  done  in  two  stages  with 
an  interval  for  the  formation  of  ad- 
hesions, or  it  may  be  done  in  a  single 
sitting,  the  cyst  being  sutured  to  the 
operation  wound  before  incision. 

Neoplasms. — A  single  focus  of  pri- 
mary cancer  may  sometimes  be 
removed  by  hepatectomy ;  sarcoma  is 
inoperable. 

Cirrhosis, — This  has  been  con- 
sidered under  Ascites  (Surgery  of 
Peritoneum). 

Hepatoptosis. — Hepatopexy  is  done 
usually  in  conjunction  with  other 
operations.  The  liver  is  scarified  or 
brushed  on  the  cephalad  surface,  and 
one  of  several  methods  in  addition  for 
retaining  it  in  situ  are  essayed.  The 
author  includes  shortening  of  the  sus- 
pensory ligament. 

Cholelithiasis. — Simple  accumula- 
tion of  gall-stones,  apart  from  the 
complication  and  secondary  mischief, 
demands  surgical  removal.  The 
choice  then  lies  between  cholecystos- 
tomy  and  cholecystectomy. 

Cholecystitis. — When  the  gall-blad- 
der has  become  chronically  inflamed, 
altered  by  disease  and  adhesions,  it 

1- 


should  be  extirpated.  Partial  chole- 
cystectomy is  not  looked  upon  with 
favor.  If  the  process  is  relatively 
mild,  with  the  ducts  free  and  intact, 
cholecystostomy  may  suffice,  but, 
like  the  appendix,  a  gall-ldadder  once 
infected  is  always  infected. 

Obliteration  of  Bile-passages  from 
Without. — This  is  most  commonly 
due  to  cancer,  but  may  be  due 
to  other  tumors  and  inflammatory 
processes.  The  typical  operation  for 
obstruction  from  without  is  an 
anastomosis  between  gall-bladder 
and  intestine  (cholecystenterostomy). 
When  this  is  contraindicated  perma- 
nent drainage  by  a  biliary  fistula 
(cholecystostomy)  is  the  only  resort. 

TYPICAL  OPERATIONS  ON 
BILIARY  PASSAGES  AND 
LIVER. — These  are  few  in  number, 
viz.,  cystostomy,  cystectomy,  and  cho- 
ledochotomy,  cholecystenterostomy, 
excision  of  liver.  Other  operative 
procedures  appear  to  necessitate  only 
general  principles,  such  as  explora- 
tory laparotomy,  evacuation  of  pus, 
etc.  The  typical  operations  on  the 
biliary  passages  are  performed  for 
cholelithiasis,  incidentally  including 
chronic  cholecystitis. 

Analysis  of  350  operative  gall-bladder 
cases,  derived  mainly  from  material 
furnished  by  A.  J.  Ochsner.  Where 
the  benefit  derived  from  the  operation 
has  not  been  unquestionable  the  result 
is  stated  as  unimproved.  In  245  cases 
where  gall-stones  were  found,  79  per 
cent,  report  themselves  entirely  cured 
by  the  operation  and  6  per  cent,  consider 
themselves  as  cured  though  still  suf- 
fering from  minor  discomforts.  This 
gives  85  per  cent,  good  results. 
Twenty-one,  or  9  per  cent.,  are  classed 
as  improved,  and  IS,  or  6  per  cent,  as 
doubtful.  The  writer's  conclusions  are 
as  follows :  1.  In  the  hands  of  those 
qualified    to    undertake    the    work,    the 


98 


ABDOMEN,    SURGERY    OF    (MORRIS). 


operative  treatment  of  gall-stone  dis- 
ease is  one  of  the  most  satisfactory 
branches  of  surgery,  and  the  cures  may 
be  safely  estimated  at  over  80  per  cent., 
while  the  majority  of  the  remainder 
are  so  much  benefited  as  to  justify  the 
operation.  2.  The  most  favorable  cases 
in  all  respects  are  those  in  which  the 
stones  are  still  confined  to  the  gall- 
bladder. The  operative  mortality  in 
these  uncomplicated  cases  is  almost  nil, 
and  the  proven  end  results  are  prac- 
tically all  that  could  be  desired.  These 
two  facts  in  themselves  should  enable 
us  to  settle  any  question  as  to  the 
proper  time  for  operation.  3.  The 
most  important  principle  of  gall-stone 
surgery  is  the  complete  removal  of  the 
stones,  with  the  least  possible  damage 
to  the  biliary  tract.  Overlooked  stones 
are  probably  the  most  important  simple 
cause  of  uncured  patients.  4.  If,  as  a 
result  of  the  operation,  all  obstructions 
within  the  biliary  tract  are  removed, 
a  cure  is  almost  certain  to  result.  No 
evidence  has  been  found  in  this  series 
of  cases  to  show  that  cholecystectomy 
should  ever  be  the  operation  of  choice 
in  gall-stone  cases,  unless  there  be 
chronic  cystic  duct  obstruction  or  the 
gall-bladder  so  diseased  as  to  make  a 
cholecystectomy  technically  safer  and 
easier  to  perform  than  a  cholecystos- 
tomy.  5.  Every  effort  should  be  made 
to  guard  against  postoperative  hernia. 
6.  A  guarded  prognosis  should  be 
given  in  cases  complicated  by  pelvic 
lesions.  7.  In  our  series,  cases  of 
cholecystitis  without  stones  have  not 
shown  better  results  than  could  probably 
have  been  attained  by  medical  means, 
and  unless  better  results  are  attained  in 
this  class  of  cases  in  the  future  sur- 
geons should  learn  to  avoid  them.  E. 
M.  Stanton  (Jour.  Amer.  Med.  Assoc, 
Aug.  5,  1911). 

Simple  Cystotomy. — The  gall-blad- 
der, having  been  exposed,  is  incised 
between  two  toothed  forceps,  and  the 
stones  if  present  removed  with  finger 
or  blunt  curet,  taking  care  to  remove 
all  possible  concrements,  some  of 
which  may  lie  close  to  or  in  the  open- 


ing of  the  cystic  duct.  One  finger 
should  be  applied  along  the  bladder 
externally,  to  aid  in  localizing  con- 
crements. Folds  and  diverticula 
resulting  from  cholecystitis  may  con- 
tain concrements.  The  cystic  duct 
and  common  duct  must  be  palpated 
and,  if  stones  are  contained  therein, 
choledochotomy  may  be  required. 
The  author  prefers  amputation  of  the 
greater  part  of  the  gall-bladder  as  a 
rule,  because  it  removes  an  infected 
structure  and  avoids  the  distress 
caused  by  the  lower  margin  of  the 
liver  impinging  upon  a  gall-bladder 
sutured  to  the  abdominal  wall. 

Cyst  ostomy. — Cystostomy  with 
Drainage. — This  form  of  cystostomy 
is  really  then  a  partial  cystectomy. 
The  tube  remains  in  position  eight  or 
ten  days,  the  bile  escaping  freely. 
After  the  tube  has  been  withdrawn, 
a  little  bile  may  escape  up  to  a  week 
or  so  longer.  As  a  rule,  these  fistulse 
close  spontaneously  without  trouble. 

Cystectomy. — Surgeons  have 
proved  by  experience  that  cystostomy 
had  many  drawbacks.  It  is  the  con- 
servative method,  but  leaves  behind  a 
diseased  gall-bladder,  which  invites 
new  surgical  disorders.  Adhesions 
which  are  invariably  present  cause 
the  organ  to  lose  its  mobility,  thus 
increasing  the  liability  to  further  in- 
fection. Cystectomy,  an  operation 
originally  performed  only  on  suspi- 
cion of  cancer,  has  been  the  choice  of 
the  author  for  some  years,  the  sug- 
gestion having  come  from  Langen- 
beck's  discovery  of  the  safety  of 
extirpation  of  the  organ  originally, 
and  this  idea  confirmed  by  many 
operators  later. 

Excepting  in  cases  of  cancer  the 
author  prefers  the  same  operation 
for  cystectomy  that  he  does  for  cys- 


ABDOMEN,    SURGERY    OF    (MORRIS). 


99 


tosUuiU',  for  the  reasDii  thai  the  small 
portion  of  i^all-bladdcr  which  is  al- 
lowed to  remain  alUnvs  of  easier 
fastening  to  the  drainage  tnbe,  and 
lessens  the  annoyance  of  hemorrhage 
from  the  artery  and  vein  of  the  cystic 
duct. 

TccJuiiquc. — The  gall-bladder,  hav- 
ing been  exposed,  is  freed  from  adhe- 
sions and  from  the  normal  peritoneal 
reflection  to  the  surface  of  the  liver. 
The  presence  or  absence  of  gall- 
stones in  the  bladder  is  only  of  inci- 
dental importance,  because  it  is  for 
infection  of  the  gall-bladder  that  the 
operation  is  done.  The  freed  gall- 
bladder can  be  handled  very  much  as 
one  v^ould  handle  the  appendix,  and 
the  operation  from  this  stage  on  is 
somewhat  similar.  Any  bile  or  con- 
cretions which  are  found  in  the  lower 
part  of  the  gall-bladder  or  the  cystic 
duct  are  stripped  out  with  the  fingers 
into  the  cavity  of  the  gall-bladder 
proper,  which  remains  unopened.  The 
part  which  has  been  emptied  by  strip- 
ping with  the  fingers  is  then  ligated 
or  clamped  with  a  pair  of  forceps  to 
prevent  the  return  of  contents  to  the 
region  of  the  operation.  A  longi- 
tudinal incision  large  enough  to 
allow  the  entrance  of  a  small  soft- 
rubber  catheter  is  then  made  below 
the  clamp  or  ligature,  and  extending 
as  far  as  or  into  the  lumen  of  the 
cystic  duct.  The  catheter  is  intro- 
duced into  this  opening  and  tied  in 
place  with  a  catgut  suture  piercing 
the  wall  of  the  cystic  duct  and  cathe- 
ter alike.  This  avoids  displacement 
caused  by  vomiting.  The  next  step 
consists  in  tying  another  catgut 
suture  snugly  around  the  cystic  duct 
or  the  lower  portion  of  the  gall- 
bladder so  firmly  as  to  cut  off  all 
circulation    in    the   walls.      The   Sfall- 


Idadder  is  then  ami)utated  between 
the  clamp  and  ligature,  and  the  lumen 
of  the  slump  at  the  point  of  com- 
pression by  the  ligature  may  be  steri- 
lized like  the  stump  of  the  appendix, 
by  brushing  it  with  95  per  cent,  car- 
bolic acid  neutralized  a  moment  later 
with  alcohol.  The  catheter,  acting 
as  a  drainage  tube,  is  then  left  escap- 
ing from  any  convenient  angle  of  the 
wound  of  the  abdominal  wall.  In 
two  or  three  days  the  constricting 
suture  is  usually  absorbed  and  the 
flow  of  bile  then  begins  through  the 
tube,  which  can  be  removed  at  any 
time  subsequently,  because  the  suture 
of  catgut  fastening  the  catheter  to 
the  cystic  duct  is  absorbed  at  the 
same  time  with  the  constricting 
suture.  The  advantage  of  this  tech- 
nique is  that  peritoneal  adhesions 
have  had  time  to  wall  in  the  area  of 
operation  so*  that  bile  or  septic  fluid 
escaping  from  the  region  of  the  stump 
makes  its  way  safely  to  the  surface. 
Sometimes  it  is  an  advantage  to  split 
the  catheter  longitudinally  through- 
out its  entire  length,  and  to  lay  a 
strand  of  gauze  loosely  in  the  cathe- 
ter because  this  gives  us  capillary 
attraction  to  help  in  guiding  bile  or 
septic  fluid  to  the  surface;  and  if  the 
walls  of  the  catheter  are  prevented 
from  closing  entirely,  any  blood  or 
other  fluid  between  the  stump  and 
the  external  incision  is  drawn  out  the 
same  way  by  capillarity. 

Some  surgeons  do  not  consider 
partial  excision  as  a  typical  operation. 
They  state  that  cases  occur  in  which 
the  gall-bladder  is  so  fragile  that  its 
liberation  would  be  impossible,  but 
such  cases  make  a  small  part  of  the 
ones  actually  dealt  with  in  practice, 
and  practically  the  same  principles 
can  be  observed. 


100 


ABDOMEN,   SURGERY   OF    (MORRIS). 


The  writer's  only  contraindications 
to  choiecystectomy  are  :  1.  Grave  com- 
plicating diseases,  e.g.,  typhoid  fever. 
Even  in  the  latter,  he  advocates  sub- 
sequent ren::oval  of  the  gall-bladder  to 
prevent  as  far  as  possible  the  patient 
becoming  a  typhoid  carrier.  2.  Com- 
plete obstructive  jaundice.  A  second- 
stage  removal  of  the  gall-bladder  is 
also  indicated  here,  especially  if  the 
patient  has  signs  of  hepatic  cirrhosis. 
3.  In  aged  or  feeble  patients  and  in 
those  who  take  the  anesthetic  badly,  so 
as  to  save  time  and  shock.  H.  Lilien- 
thal   (N.  Y.  Med.  Jour.,  July  1,  1911). 

Choledochotomy. — This  operation 
comes  into  play  Avhen  after  cystec- 
tomy the  common  duct  or  the  hepatic 
duct  is  found  diseased  or  containing 
concrements.  A  wide  external  inci- 
sion is  requisite  when  it  is  believed 
that  this  operation  is  indicated.  Ex- 
posure may  be  difficult  on  account  of 
the  conformation  of  the  thorax,  or 
when  adiposity  interferes.  It  may  be 
necessary  in  such  cases  for  an  assist- 
ant to  draw  aside  all  the  surrounding 
viscera  widely  with  the  liands^  with 
gauze  beneath  the  fingers.  If  adhe- 
sions are  absent  the  common  duct 
may  be  lifted  into  the  field  with  the 
fingers  or  a  pair  of  padded  forceps. 
The  peritoneal  covering  is  slit.  The 
large  vessels — hepatic  artery  and 
portal  vein — behind  the  biliary  pas- 
sages are  to  be  avoided.  A  small 
vessel  running  obliquely  across  these 
must  be  held  aside  or  tied  and 
divided.  Two  lymph-glands  in  this 
locality  may  be  so  enlarged  and  in- 
flamed as  to  simulate  concrements. 
The  common  duct  must  now  be 
examined  for  concrements  and  in- 
flamrnation.  If  concrements  are  pal- 
pable, the  duct  is  opened  between 
slipnooses  or  forceps.  Bile  will  at 
once  escape  and  must  be  caught  up 
with  gauze  pledgets  and  the  stones, 


if  present,  removed  with  small  forceps 
or  curets. 

As  a  rule,  however,  extensive  ad- 
hesions are  present,  and  the  opera- 
tion is  much  more  complicated. 
These  adhesions  must  be  separated 
as  far  as  possible,  and  if  the  cystic 
duct  has  not  already  been  opened  it 
should  be  incised.  If  the  object  were 
not  primarily  to  extirpate  the  gall- 
bladder, this  should  now  be  done  and 
the  cystic  duct  divided.  The  chole- 
dochus  should  next  be  sounded 
through  the  opening,  the  finger  pal- 
pating the  outside  of  the  canal.  If 
concrements  are  present,  the  cystic 
duct  may  be  laid  open  slowly  until 
the  common  duct  is  reached.-  By  the 
aid  of  small  curets  and  forceps,  and 
palpation  externally,  small  concre- 
ments may  be  extracted.  If  neces- 
sar}"-  the  incision  may  be  continued 
into  the  common  duct  as  far  as  the 
duodenum.  Extraction  of  stones 
from  an  inflamed  or  dilated  chole- 
dochus  requires  the  same  precautions 
as  in  the  case  of  the  gall-bladder. 
That  portion  of  the  duct  behind  the 
duodenum  is  very  difficult  of  access, 
unless  the  reflection  of  peritoneum 
from  the  duodenum  is  first  cut  away. 
In  cases  of  this  sort  it  has  been  neces- 
sary to  enter  the  duodenum. 

The  conservative  method  is  to 
draw  the  duodenum  to  one  side  after 
freeing  the  peritoneum,  but  this  is 
believed  by  some  to  affect  the  nutri- 
tion of  the  latter  unfavorably.  A 
drainage  tube  is  inserted  into  the 
choledochus,  and  the  latter  sutured 
up  to  the  tube  by  most  operators,  but 
the  author  usuall}^  dispenses  with 
sutures,  excepting  the  single  one  for 
holding  the  tube  in  place,  because 
the  walls  of  the  duct  normally  fall 
together  well,  and  atmospheric  pres- 


ABDOMEN,    SURGERY    OF    (MORRIS). 


101 


sure  keeps  the  cut  margins  together 
as  well  as  sutures  would  do  it,  unless 
much  unusual  injury  has  been  caused 
b_y  the  operative  work. 

Case  of  bile  fistula  in  which  it  was 
not  possible  to  utilize  the  hepatic  duct 
for  drainage;  the  writer  consequently 
sutured  the  duodenum  directly  to  the 
main  intrahepatic  biliary  duct.  Doberer 
(\\'icncr  klin.  Woch.,  Oct.   13,  1910). 

Cholecystenterostomy.  —  A  typical 
operation  indicated  is  closure  of  the 
biliary  passages  from  without.  A 
long  abdominal  incision  is  required, 
oblique  or  angular,  beginning  at  the 
ensiform  cartilage  and  carried  down 
through  the  right  rectus  muscle. 
The  intestines  are  controlled  by 
gauze.  If  gall-stones  are  present  they 
are  removed,  and  it  must  also  be 
determined  that  suspected  cancer  of 
the  pancreas  is  not  a  calculus  in  the 
pancreatic  region.  A  choice  of  intes- 
tinal locality  for  anastomosis  is  then 
in  order. 

The  duodenum  is  the  ideal  region, 
but  in  practice  a  high  jejunal  anasto- 
mosis is  often  preferable.  The  gall- 
bladder is  emptied  upon  gauze,  and 
the  apex  seized  with  a  clamp.  A  loop 
of  jejunum  is  similarly  held  with  the 
fingers.  Both  structures  are  opened 
to  the  extent  of  a  finger-tip,  as  in 
gastroenterostomy,  and  the  suture  is 
also  performed  as  in  the  latter.  This 
locality  may  be  fortified  with  omen- 
tum, if  the  operator  wishes. 

The  Alurphy  button  is  useful  for 
this  anastomosis  and  is  used  by  many 
operators,  but  simple  suture  suffices 
for  most  cases. 

Excision  of  Liver;  Hepatectomy. — 
Indicated  in  tumors  chiefly,  inckiding 
cysts,  and  sometimes  after  trauma- 
tisms. When  a  pedicle  is  present  or 
the  mass  occupies  the  margin  of  the 


liver,  hepatectomy  is  very  easily  per- 
formed by  the  aid  of  ligation. 

When  this  is  impossible  the  mass 
is  removed  step  by  step,  followed  by 
ligation  of  all  bleeding  vessels.  It  is 
often  possible  to  ligate  these  in  ad- 
vance of  division  v/ith  a  needle  armed 
with  catgut.  After  extirpation  it  is 
in  order  to  ligate  all  lumina  of  blood- 
vessels with  the  aid  of  a  needle  rather 
than  with  forceps,  and  then  suture 
the  liver  with  catgut.  Buried  sutures 
are  undesirable  for  the  liver,  however, 
as  blood  and  bile  seep  into  them. 
Pressure  may  be  brought  to  bear  for 
controlling  hemorrhage  that  is  not 
from  spouting  vessels,  in  some  cases. 
Pressure  is  obtained  by  carrying  a 
long  catgut  ligature  deeply  through 
the  wound  in  the  liver,  and  fastening 
each  end  of  catgut  to  a  broad  plate 
of  sheet  lead.  If  the  entering  end  of 
catgut  is  first  fastened  to  its  respect- 
ive plate  of  lead,  the  emerging  end  of 
catgut  can  be  tightened  to  any  de- 
sirable extent  before  fastening  it  to 
the  second  lead  plate.  Ears  fash- 
ioned on  the  lead  plates  can  be  bent 
over  to  hold  the  catgut  ends,  and  silk 
strands  fastened  to  the  plates  and  led 
out  of  the  wound  serve  for  removing 
the  plates  eventually  when  the  catgut 
is  absorbed.  More  than  one  pair  of 
plates  may  be  used  for  an  extensive 
liver  wound. 

Extensive  resections  of  the  liver  can 
be  carried  out  with  the  most  simple 
means.  If  care  is  taken  not  to  stretch 
the  vessels  in  cutting  through  the  liver 
and  not  to  pull  them  out,  it  is  not  diffi- 
cult to  apply  hemostatic  forceps  and  to 
apply  a  ligature,  while  the  vessels 
which  are  cut  obliquely  have  to  be 
taken  care  of  by  circular  suture.  Com- 
pression suture  of  the  wound  in  the 
liver  and  catgut  suture  of  the  surface 
are  the  safest  means  of  hemostasis.  It 
is  best  to  press  together  two  wounded 


102 


ABDOMINAL   INJURIES    (LAPLACE). 


surfaces  of  the  liver  by  suture,  and, 
therefore,  whenever  possible,  to  make 
the  resection  in  the  shape  of  a  wedge 
placed  in  an  approximately  vertical 
direction  to  the  margin  of  the  organ. 
Garre  (Surg.,  Gynec.  and  Obstet.,  Sept., 
1907). 

Robert  T.  Morris,  M.D., 

New  York. 


ABDOMINAL  INJURIES.— 

Under  this  heading-  will  be  considered 
the  broad  field  of  injuries  of  external 
origin  to  which  the  abdomen  and  the 
abdominal  viscera  are  liable.  These 
include  contusions,  which  are  impor- 
tant mainly  because  of  the  lesions  to 
which  the  intra-abdominal  organs  are 
exposed;-  non-penetrating  zvounds,  in 
which  the  abdominal  walls  alone  are 
injured,  and  penetrating  zvounds,  in 
which  the  walls  and  the  abdominal 
viscera  are  penetrated. 

CONTUSION  OF  THE  ABDO- 
MEN.—SYMPTOMS.— Whether 
caused  by  blows,  kicks,  spent  bullets, 
the  passage  of  heavy  bodies — such  as 
vehicles — over  the  abdomen,  etc.,  the 
symptoms  attending  a  contusion  in 
this  region  are  not  always  such  as  to 
call  attention  to  the  seriousness  of 
the  lesion  present.  The  gravest  ab- 
dominal injuries  may  coexist  with 
practically  no  external  or  general  in- 
dication of  mischief,  the  patient  walk- 
ing a  long  distance,  perhaps,  without 
experiencing  anything  more  than 
slight  local  pain  where  the  blow  had 
been  received. 

Case  of  patient  run  over  by  a  milk 
wagon,  in  which  no  serious  disturbance 
manifested  itself  until  about  eleven 
weeks  after  the  injury  occurred.  The 
patient  then  noticed  a  lump  about  the 
size  of  a  hen's  egg  near  McBurney's 
point.  Two  weeks  later  the  swelling 
ruptured  and  some  pus  was  discharged. 
The     mass     consisted     of     suppurating 


omentum,  with  partial  rupture  of  the 
aponeuroses  of  the  external  oblique  and 
a  localized  rupture  of  the  muscular  por- 
tion of  the  internal  oblique  and  trans- 
versalis  muscles.  Recovery  followed 
suitable  treatment.  Kahlke  (Surg., 
Gynec.  and  Obstet.,  Feb.,  1907). 

Intestinal  lesions  produced  by  blunt 
force  are  most  frequently  encountered 
in  males  during  youth  and  early  man- 
hood, and  in  females  during  childhood, 
these,  of  course,  being  the  periods  of 
greatest  exposure  to  trauma.  Pre-ex- 
isting lesions,  such  as  hernias,  ulcers, 
adhesions,  etc.,  increase  the  liability  of 
rupture  should  trauma  occur.  Lax  ab- 
dominal muscles  afford  less  protection 
than  a  wall  which  is  contracted,  and 
hence  very  sudden  accidents  are  more 
frequently  the  cause  of  visceral  lesion 
than  those  in  which  the  patient  has 
some  warning.  All  parts  of  the  gastro- 
intestinal tract  have  been  injured,  to 
say  nothing  of  the  other  abdominal 
viscera,  but  the  ileum  and  jejunum  are 
more  often  involved,  the  colon  and 
stomach  less  frequently.  Thus  in  219 
cases,  the  small  intestine  was  affected 
172  times,  the  large  26  times,  and  the 
stomach  only  21  times.  That  vomiting 
is  apt  to  arise  sooner  if  the  lesion  be 
above  the  level  of  the  umbilicus  than  if 
it  be  below  is  probable.  Stone  (Annals 
of  Surg.,  Sept.,  1910). 

In  all  injuries  of  the  abdominal 
viscera  without  external  lesions  careful 
examination  is  necessary  and  contin- 
uance of  the  observation  kept  up  over 
a  period  of  several  days  or  more.  No 
matter  how  slight  the  S}'mptoms  refer- 
able to  the  abdomen,  the  possibility  of 
visceral  injury  must  be  considered,  re- 
gardless of  the  point  of  injury  or  the 
external  force  employed.  The  degree 
of  violence  has  often  no  relation  to  the 
extent  or  severity  of  the  injury  to  the 
internal  organs,  and  an  investigation  as 
to  the  exact  details  of  the  accident  or 
violence  is  essential  for  the  diagnosis. 
Blows,  kicks,  and  crushing  violence 
cause  most  of  the  intestinal  injuries; 
compressive  force  is  the  most  common 
cause  of  liver  trauma,  and  concussion  is 
responsible  for  most  of  the  splenic  rup- 
tures.    The     presence     or     absence     of 


ABDOMINAL   INJURIES    (LAPLACE). 


103 


peristalsis  is  of  the  utmost  dicignostic 
and  prognostic  importance  and  lias  not 
been  duly  appreciated.  The  early  pres- 
ence of  a  peristalsis  indicates  that  the 
abdomen  or  its  contents  have  received 
some  shock  or  violence,  and  its  per- 
sistence or  recurrence  is  a  conclusive 
proof  of  internal  or  visceral  injury. 
Any  decided  lessening  of  peristalsis  is 
a  danger  signal  if  it  occurs  more  than 
three  or  four  hours  after  the  injury. 
Active  peristalsis,  on  the  other  hand,  is 
always  encouraging.  There  are  no 
■pathognomonic  symptoms  of  abdominal 
injuries,  most  of  them  being  common 
to  all  injuries,  but,  in  general,  progress- 
ively increasing  shock  indicates  trauma 
of  the  solid  organs,  while  early  symp- 
toms of  peritonitis  follow  that  of  the 
stomach  or  intestines.  Pain  as  an  in- 
itial symptom  is  important  only  as  call- 
ing attention  to  the  fact  that  an  injury 
may  have  occurred  and,  possibly,  by  its 
location,  showing  the  possible  site  of 
the  injury.  Shock  has  no  diagnostic 
value  except  by  its  progress  or  course, 
which  is  of  great  importance.  H.  H. 
Sherk  (Jour.  Amer.  Med.  Assoc, 
March,   1911). 

Althoug-h  the  abdominal  walls  may 
be  but'  slightly  injured,  the  lesions 
may  consist  of  extensive  extravasa- 
tions of  blood  between  the  layers,  or 
sufficient  laceration  of  the  muscular 
and  other  tissues  to  give  rise  to  more 
or  less  local  sloughing.  Such  lesions 
of  the  abdominal  wall,  however,  are 
not  always  accompanied  by  injury  of 
the  abdominal  organs. 

Usually,  in  these  cases,  according 
to  Scudder,  the  greater  the  force  the 
greater  the  injury,  but  a  trivial  blow 
may  result  in  serious  damage  to  intra- 
abdominal viscera.  A  hollow  organ, 
if  distended,  is  more  vulnerable  than 
if  empty.  Inquiry  should  be  made  as 
to  the  last  mealtime  and  as  to  the 
last  micturition.  The  exact  direction 
of  the  blow  is  important.  The  clothes 
of  the  patient  sometimes  offer  some 
indication  as  to  the  injury. 


A  trifling  superficial  injury  of  the 
aljdominal  wall  may  be  associated 
with  serious  internal  lesions,  owing 
to  the  resistance  offered  by  the  ab- 
dominal walls  and  the  fragility  of  the 
abdominal  organs.  The  external  ap- 
pearances, therefore,  should  not  be 
taken  as  a  criterion. 

From  observations  of  some  twenty 
cases  of  visceral  injury,  following- 
contusion 'of  the  abdomen,  verified  by 
operation  or  autopsy  by  Brewer,  the 
most  prominent  were  pain,  tender- 
ness and  muscular  rigidity,  and  like- 
wise the  most  reliable.  The  deep- 
seated,  localized  pain  following  injury, 
especially  increased  by  pressure,  and 
accompanying  local  or  general  mus- 
cular rigidity,  is  one  of  the  most 
constant  signs  of  intra-abdominal 
injury.  Brewer  holds  that  the  asso- 
ciation of  these  three  symptoms  is 
almost  pathognomonic  of  abdominal 
irritation.  Pain,  however,  is  often 
present,  with  tenderness,  in  injuries 
limited  to  the  abdominal  wall;  but  in 
these  instances  muscular  rigidity  is 
generally  absent.  In  the  absence  of 
subcutaneous  pain  localized  tender- 
ness with  rigidity  is  strongly  sug- 
gestive of  visceral  injury.  Of  the 
three  symptoms,  muscular  rigidity  is 
the  most  reliable,  and  sometimes  the 
only  sign.  In  the  absence  of  other 
diseased  conditions  spasm  of  one  or 
more  of  the  abdominal  muscles  fol- 
lowing the  traumatism  may  be  looked 
upon  as  nature's  effort  to  protect  an 
injured  organ  from  further  irritation. 
Vomiting  is  a  symptom  often  present, 
but  not  always  an  accompaniment  of 
severe  visceral  injury.  It  is  com- 
monly present  with  involvement  of 
the  stomach  and  upper  part  of  the 
intestinal  tube,  and  with  injuries 
resulting  in  severe  shock.     The  signs 


104 


ABDOMINAL   INJURIES    (LAPLACE). 


of  free  fluid  in  the  abdominal  cavity 
are  very  suggestive. 

In  most  cases,  however,  severe 
contusions  of  the  abdominal  wall, 
whether  the  deep  organs  are  involved 
or  not,  are  followed  by  agonizing 
pain  in  the  region  of  the  injury,  rest- 
lessness, nausea  or  vomiting,  marked 
prostration  (indicated  by  a  small, 
rapid,  and  irregular  pulse),  pallor 
(sometimes  attaining  lividity),  cold 
sweats,  rigidity  of  the  abdominal 
wall,  meteorism,  anxiety,  and  fear  of 
a  fatal  issue. 

A  very  rapid  and  considerable  me- 
teoric distention  coming  on  after  a 
contusion  of  the  abdomen  does  not  of 
itself,  in  the  absence  of  characteristic 
signs  and  when  the  pulse  is  good,  point 
to  a  rupture  of  any  of  the  viscera,  or 
to  an  internal  hemorrhage.  Lejars 
(Semaine  medicale,  Oct.  30,  1907). 

All  these  symptoms  bear  the  im- 
print of  a  severe  nervous  commotion, 
and,  if  the  extensive  distribution  of 
the  sympathetic  nervous  system  in 
the  abdominal  cavity  is  borne  in 
mind,  the  fact  will  become  evident 
that  symptoms  usually  witnessed  im- 
mediately after  the  receipt  of  the 
injury  are  due  mainly  to  the  influence 
of  the  concussion  upon  the  sym- 
pathetic supply.  Sudden  death  has 
been  known  to  follow  a  violent  blow, 
especially  when  received  in  the  region 
of  the  solar  plexus. 

Any  contusion  of  the  abdomen  may 
induce  symptoms  of  shock.  It  is  im- 
possible to  determine  the  extent  of  the 
internal  injury  from  the  presence  or 
the  intensity  of  the  shock  or  the  total 
absence  of  signs  of  shock.  The  writer 
has  had  patients  with  severe  laceration 
of  the  liver  or  rupture  of  the  bowel 
who^  were  able  to  repair  to  the  hospital 
on  foot.  Subnormal  temperature  may 
be  due  to  the  shock  and  anemia;  fever 
soon  after  the  trauma  shows  an  in- 
flammatory process.  The  pulse  and 
heart  action   are  not  influenced  by  in- 


ternal injury  except  in  case  of  anemia 
or  peritonitis.     Nausea  and  vomiting  do 
not     necessarily     accompany     anatomic 
injury.     Foderl    (Med.   Klinik,   Oct.  30, 
1910). 
The   pain   varies   according   to   the 
location   of   the   traumatism   and   the 
sensitiveness    of    the    patient.      Very 
severe  at  first,  it  usually  becomes  less 
marked    after    a    few    hours.      It    is 
greatly  influenced  by  shock,  profound 
prostration  reducing  its  intensity  by 
reducing    sensation.      Great    restless- 
ness usually   accompanies  abdominal 
pain  after  injuries,  as  well  as  during 
other   diseases,   such   as   appendicitis, 
when  the  suffering  is  due  to  a  local- 
ized    trouble.       The     pain     may     be 
radiated    in    various    directions, — the 
shoulder,     the     umbilicus,     the     left 
axilla,    the    testicles,    etc., — according 
to    the    site    of    the    primary    lesion. 
Local   tenderness    is   usually   marked 
over  the  site  of  the  traumatism. 

Rigidity  of  the  abdominal  muscles, 
attended  with  dullness,  even  slight  in 
degree,  and  local  tenderness,  are  most 
valuable  points  in  the  diagnosis  of  these 
injuries,  and  where  they  exist,  and  espe- 
cially if  a  blood-count  shows  an  active 
leucocytosis,  operation  is  demanded  and 
no  time  should  be  lost  in  performing  it. 
It  is  very  hard  to  convince  the  patient 
and  his  friends  of  the  actual  condition, 
and  they  will  invariably  plead  for  delay. 
The  serious  condition  should  be  early 
pointed  out,  and  every  effort  made  to 
secure  consent  to  operate  while  the  con- 
dition of  the  patient  renders  success 
probable. 

These  cases  are  most  inevitably  fatal 
without  operation,  and  the  effect  of  an 
exploratory  incision  while  the  patient  is 
in  a  fair  condition  is  not  serious  enough 
to  counterbalance  the  advantages  to  be 
gained  if  rupture  of  any  of  the  organs 
is  found  to  exist.  W.  G.  Weaver 
(Penna.  Med.  Jour.,  July,  1904), 

Protest  against  the  administration  of 
opium  or  other  narcotics  until  the  diag- 
nosis is  positive,  because  they  obscure 
the  clinical  picture,  the   diagnosis,  and 


ABDOMINAL   INJURIES    (LAPLACE). 


105 


the  indications  for  treatment.  They 
should  be  reserved  for  use  in  cases  in 
which  the  diagnosis  is  positive,  or  in 
which  both  removal  and  operation  are 
impossible  on  account  of  surrounding 
conditions,  or  in  those  cases  in  which 
the  inj.ury  is  so  serious  that  death  is 
inevitable.  Foderl  (Med.  Klinik,  Oct. 
30,   1910). 

The  vomiting-  varies  greatly  in 
intensity  from  mere  nausea  to  the 
most  violent  expulsive  efforts,  which 
are  liable,  by  the  strain  upon  the 
abdominal  organs,  to  suddenly  in- 
crease the  extent  of  the  lesions.  The 
vomited  matter  sometimes  contains 
blood,  especially  if  the  upper  portion 
of  the  digestive  tract  is  involved  in 
the  injury.  Constant  and  persistent 
vomiting-  tends  to  indicate  a  contu- 
sion accompanied  by  visceral  lesions. 
According  to  Berndt,  in  simple  cases 
the  vomiting  is  repeated  but  two  or 
three  times.  When  the  intestine  is 
ruptured  the  vomiting  is  persistent 
and  intractable  and  liver-dullness  is 
absent. 

The  degree  of  shock  depends  upon 
the  nature  and  extent  of  the  injury 
and  especially  upon  the  amount  of 
blood  lost.  When  the  signs  of  col- 
lapse gradually  become  more  marked, 
internal  hemorrhage  from  rupture  of 
one  or  more  of  the  viscera  is  to  be 
feared. 

The  pulse,  usually  rapid  and  weak 
at  first,  gradually  becomes  stronger 
and  slower  if  a  favorable  reaction  is 
about  to  take  place.  If,  on  the  con- 
trary, an  unfavorable  course  is  being 
taken  and  some  complication  is  to 
occur,  its  rapidity  and  tension  may 
become  increased.  Irregularity  is 
not  a  favorable  indication  if  it  per- 
sists. Temperature  is  independent  of 
the  pulse,  except  when  a  favorable 
reaction  is  taking  place,  when  it  may 


return  to  the  normal  line  after  havinsf 
gone  beyond  or  below  it.  The  usual 
belief  that  a  subnormal  temperature 
always  follows  internal  hemorrhage 
is  fallacious ;  for  it  may  also  be  raised. 
The  temperature,  therefore,  is  of  no 
value  as  a  guide. 

Hematemesis  may  assist  in  estab- 
lishing the  diagnosis  of  lesion  in  the 
stomach  or  the  upper  portion  of  the 
intestinal  tract,  while  the  presence  of 
blood  in  the  stools  may  do  the  same 
as  regards  lesions  of  the  intestines  as 
a  whole,  including  the  colon.  But, 
in  itself,  this  symptom  is,  by  no 
means,  characteristic,  since  a  violent 
strain  may  cause  sudden  engorge- 
ment of  pharyngeal,  gastric,  rectal, 
or  hemorrhoidal  vessels  and  then, 
several  days  after  the  accident,  blood- 
rupture  ensue.  Even  when  present, 
streaks  in  vomited  matter  or  stools 
are  not  always  indicative  of  an  alarm- 
ing condition. 

Blood  in  the  urine  is  a  more  reliable 
sign  of  lesion  in  the  urinary  tract, 
especially  the  kidney  and  bladder. 
Anuria  is  also  indicative  of  lesions  in 
these  organs ;  but,  as  shock  frequently 
arrests  the  flow  of  urine,  it  is  only 
valuable  as  a  symptom  after  all  symp- 
toms of  shock  have  passed. 

Hemorrhage  into  the  orbits  and 
from  the  ears  are  occasionally  met 
with  "when  the  concussion  has  been 
very  severe.  This  symptom  does  not 
necessarily  indicate  that  the  injury 
is  an  unusually  dangerous  one. 

A  few  hours  after  the  accident  the 
pain  usually  becomes  reduced;  the 
patient  may  be  more  quiet  and,  per- 
haps, somnolent,  although  the  pulse 
remains  in  its  former  condition.  This 
period  lasts  between  twelve  and 
twenty-four  hours.  If  at  the  end  of 
this  time  there  be   no   complication, 


106 


ABDOMINAL  INJURIES    (LAPLACE). 


a  visceral  lesion  is  probably  not 
present.  If,  on  the  contrary,  the 
symptoms  gradually  increase  in  in- 
tensity, the  likelihood  of  grave  injury 
is  very  great. 

In  the  light  of  present  knowledge, 
however,  the  practitioner  should  not 
delay  active  procedures  until  the 
patient's  life  becomes  compromised 
by  permitting  the  mechanical  injury 
produced  to  start  an  infectious  proc- 
ess, when  the  manner  in  which  the 
injury  was  inflicted  and  the  force  ap- 
plied tend  to  suggest  serious  internal 
lesion.  An  exploratory  incision  is 
sometimes  permissible  (see  colored 
plate). 

A  measure  aim  jst  devoid  of  danger  is 
the  simple,  exploratory  abdominal  inci- 
sion, to  determine  whether  or  no  a 
visceral  lesion  exists.  It  is  a  well- 
demonstrated  fact  that  any  fluid  or  ex- 
travasated  matter  in  the  peritoneal 
cavity  will  almost  invariably  present 
itself  under  the  line  of  incision  where 
the  cavity  has  been  entered,  being  forced 
there  by  the  intra-abdominal  pressure, 
and  it  is  on  this  principle  that  abdominal 
drainage  can  be  effected  against  gravity. 
The  writer  has  seen  a  large  collection 
of  pus  in  the  pelvic  cavity  drained 
through  an  opening  in  the  belly  so  com- 
pletely that  at  the  autopsy  not  a  spoonful 
remained.  It  follows,  then,  that  in  many 
cases  at  least  a  simple  incision  through 
the  abdominal  wall  will  be  all  that  is 
necessary  to  reveal  even  a  small  ex- 
travasation through  a  ruptured  yiscus. 
Of  course,  there  will  be  cases  in  which 
the  rupture  is  so  minute  as  to  preclude 
extravasation  at  the  onset,  and  such  will 
be  overlooked.  In  doing  this  little 
operation,  for,  as  a  rule,  a  short  incision 
will  be  as  effectual  as  a  longer  one,  it 
is  absolutely  necessary  that  all  bleeding 
be  checked  before  opening  the  peri- 
toneum, lest  some  of  the  blood  should 
find  its  way  into  the  cavity  and  obscure 
the  findings.  When  and  where  shall  the 
exploratory  incision  be  made  ?  At  the 
earliest  possible  moment,  for  in  this  lies 
the  salvation  of  the  patient,  and  in  the 


absence  of  contraindications  it  should 
be  made  in  the  median  line  between  the 
umbilicus  and  pubes.  D.  Tod  Gilliam 
(Monthly  Cyclo.  of  Pract.  Med.,  May, 
1907). 

Two  classes  of  cases  should  not  be 
operated  on  at  first:  (1)  Cases  in  which 
little  or  no  shock  is  present,  and  in 
which  there  are  absolutely  no  localizing 
signs ;  (2)  cases  in  which  profound 
shock,  amounting  perhaps  to  collapse, 
exists.  Immediate  operation  is  de- 
manded in  persistent  moderate  shock, 
with  or  without  localizing  signs.  Im- 
mediate operation  is  indicated  in  cases 
of  progressing  hemorrhage,  and  in  cases 
of  peritoneal  infection.  Scudder  (Bos- 
ton Med.  and  Surg.  Jour.,  May  2,  1901). 

Any  injury  to  the  abdomen,  though 
no  external  injury  occur,  may  be  asso- 
ciated with  damage  to  the  intestine  or 
other  viscera.  An  exploratory  opera- 
tion is  justifiable  in  cases  with  distinct 
rigidity.  An  operation  is  absolutely 
indicated  when  there  is,  besides  rigidity, 
pain,  tenderness,  vomiting,  shock,  dull- 
ness, or  other  symptoms  indicative  of 
some  intra-abdominal  disturbance.  Cases 
not  operated  upon  are  lost.  The  impor- 
tance of  early  operation  cannot  be 
emphasized  too  strongly.  At  present  the 
death-rate  is  about  75  to  80  per  cent. 
Flint  (Med.  Record,  Feb.  18,  1905). 

Series  of  64  cases  in  which  the  duo- 
denum was  the  seat  of  the  lesion.  An 
operation  was  done  in  28  cases,  but  in 
6  the  perforation  was  not  discovered, 
and  in  7  the  patients  succumbed  to 
shock,  hemorrhage  or  complications. 
Injury  of  the  duodenum  may  be  fol- 
lowed by  thrombosis  of, the  portal  vein. 
Notwithstanding  the  bad  prognosis, 
treatment  can  be  by  operative  measures 
only.  Small  holes  in  the  duodenum  may 
be  sutured,  but  extensive  injury  requires 
resection  of  the  intestine.  It  is  not 
particularly  difficult  and  proved  success- 
ful in  the  case  reported,  as  also  in  others 
on  record.  Transient  glycosuria  was 
observed  in  this  case  and  also  in  several 
in  the  literature.  Meerwein  (Beitrage 
z.  klin.  Chir.,  liii,  Nu.  3,  1907). 

Cases  illustrating  the  fact  that  the 
advantages  of  an  early  operation  are  too 


Abdominal  injuries  (LapLace). 


107 


great  to  warrant  waiting  until  alarming 
symptoms  develop  before  operating. 
The  diagnosis  is  not  only  dillicult  at 
first,  but  frequently  impossible,  espe- 
cially when  there  is  shock.  It  is  better 
to  operate  prudently  in  a  doubtful  case 
than  to  run  the  risk  of  compromising 
the  chances  of  success  should  operation 
he  necessary.  Patry  (Revue  nied.  de 
la  Suisse  Romande,  Feb.  20,   1909). 

DIAGNOSIS.— In  abdominal  con- 
tusions the  diagnosis  should  primarily 
be  based  upon  the  history  of  the  acci- 
dent, the  manner  in  which  the  injury 
occurred,  the  shape  of  the  body,  or  - 
bodies,  by  means  of  which  the  trau- 
matism was  inflicted,  and  the  degree 
of  percussive  force  applied,  and, 
secondarily,  upon  the  symptoms 
present. 

The  diagnosis  of  traumatic  lesions  of 
the  abdomen  is  most  difficult,  the  symp- 
toms being  variable.  When  there  is  an 
element  of  doubt  in  diagnosis,  lapa- 
rotomy is  indicated.  History  and  nature 
of  injury  may  be  the  only  indications, 
but  early  laparotomy  will  improve  the 
percentage  of  recoveries.  Laparotomy 
as  a  means  of  diagnosis  is  without 
danger.  Sellenings  (N.  Y.  Med.  Jour., 
Jan.  19..  1907). 

Method  of  abdominal  diagnosis 
which,  although  purely  clinical,  is 
known  and  largely  used  abroad,  but  in 
spite  of  its  great  usefulness  is  seldom 
heard  of  here.  This  is  the  practice  of 
making  abdominal  or  bimanual  vaginal 
examination  of  patients  while  in  a  hot 
bath.  Unless  one  has  tried  this  pro- 
cedure, it  is  difficult  to  conceive  of  its 
immense  usefulness,  for  in  many,  if 
not  most,  instances  the  abdominal 
relaxation  obtained  is  quite  equal  to 
that  obtained  under  an  anesthetic, 
with  the  added  advantage  that  the 
patient  can  help  the  examiner  by 
voluntary  movements,  such  as  deep 
inspiration,  holding  the  breath,  etc. 
This  can  be  done  in  an  ordinary 
bathtub,  in  water  as  hot  as  the  pa- 
tient can  bear;  or  if  it  is  desirable 
to  have  the  patient  higher  in  the  tub,  a 
long  sheet  may  be  let  down  over  the 


tub  into  the  water  and  fastened  about 
the  ends  of  the  tub  by  knotting  the 
corners  under  the  rolling  edge.  Carter 
(Med.  Record,  May  7,  1910). 

Lesions  of  the  Intestinal  Tract. — 

Various  theories  have  been  ad\anced 
as  to  the  manner  in  which  rupture  of 
the  intestine  is  brought  about,  but 
experiments  have  shown  that  squeez- 
ing 'of  the  gut  between  the  com- 
pressed abdominal  wall  and  the  verte- 
bral column  is  the  main  mechanical 
factor  brought  into  action. 

Five  cases  of  subcutaneous  rupture  of 
the  intestines,  with  three  recoveries.  All 
the  patients  in  this  series  were  injured 
in  one  or  two  ways.  Either  the  patient 
fell  heavily,  striking  the  front  wall  of 
his  abdomen  on  some  hard  angular 
body,  or  else  a  heavy  body  fell  on  him 
while  supine.  The  wrjter  believes  that 
in  this  way  the  bowel  is  cut  in  two  by 
the  angle  or  promontory  of  the  sacrum, 
against  which  it  is  forced  when  the 
anterior-  abdominal  wall  is  pushed 
against  the  spine.  Andrews  (Surg., 
Gynec.  and  Obstet.,  June,  1906). 

Crushing  against  the  ilium  is  rarely 
produced.  Another,  although  rare, 
cause  of  rupture  is  the  presence,  in 
the  intestinal  tract,  of  liquid  or  semi- 
liquid  material,  the  sudden  circum- 
scribed pressure  exerted  upon  the  gut 
causing  it  to  burst,  through  overdis- 
tention.  The  small  intestine'  is  the 
seat  of  lesion  in  75  per  cent,  of  the 
cases  of  rupture  in  the  course  of  the 
intestinal  canal.  Hence  the  impor- 
tance of  carefully  ascertaining  in 
each  case  the  direction  from  which 
the  percussive  force  came,  the  inten- 
sity of  that  force,  and  the  relative 
position  of  the  organs  between  the 
site  of  pressure  and  the  spinal 
column. 

Another  factor  of  importance  in  es- 
tablishing a  diagnosis  is  the  size  of 
the    instrument    causing   the    injury. 


108 


ABDOMINAL   INJURIES    (LAPLACE). 


Lesions  of  the  digestive  canal,  for 
instance,  are  usually  the  result  of 
violent  and  sudden  percussion  pro- 
duced by  a  body  over  a  limited  sur- 
face of  the  abdominal  wall. 

The  predisposing  factors  are  the 
presence  of  solid,  semisolid,  or  fluid 
matter  in  the  hollow  viscera;  lean- 
ness of  the  individual,  and  intestinal 
adhesions. 

Any  of  the  above  accidental  causes 
of  injury  being  fulfilled,  rupture  of 
some  portion  of  the  gastrointestinal 
tract  is  likely,  especially  if  there  is 
loss  of  consciousness  at  the  time  of 
the  accident,  followed  by  collapse, 
severe  pain,  a  rapid  and  weak  pulse, 
vomiting,  tympanites  due  to  the 
escape  of  intestinal  gas  into  the  ab- 
,  dominal  cavity,  and  tenderness  and 
rigidity  of  the  abdominal  walls. 

Summary  of  64  cases  found  in  the 
literature  of  injuries  of  the  duodenum 
from  contusions,  besides  one  of  his  own. 
Among  the  symptoms  noted  were  bilious 
vomiting  soon  after  the  accident,  rigid 
abdominal  walls,  absence  of  an  area  of 
dullness  over  the  liver,  localized  pain 
and  shock.  Frankel  lays  great  stress  on 
the  slow  rise  of  the  temperature  from 
hour  to  hour.  Pulse  above  100,  if 
hemorrhage  can  be  excluded,  speaks  in 
favor  of  rupture  of  the  intestines  and 
incipient  peritonitis.  Circumscribed  pain 
and  tenderness  are  indications  for  ex- 
ploratory laparotomy.  Meerwein  (Bei- 
trage  z.  klin.  Chir.,  liii,  Nu.  3,  1907). 

The  wound  of  entrance  made  by 
modern  projectiles  may  be  smaller 
than  the  diameter  of  the  bullet.  The 
firing  distance  is  of  great  importance. 
At  a  distance  less  than  300  meters 
the  explosive  manifestations  are  very 
marked;  in  distances  over  300  meters 
pure  perforations  are  produced.  The 
power  of  penetration  may  have  been 
lessened,  so  that  the  projectile  may 
lodge  in  any  organ  of  the  body; 
secondary  infection  of  other  organs 
may  follow.  The  frequent  shooting 
in  the  reclining  position  leads  to  very 


complex  injuries.  The  bullet  may 
enter  the  apex  of  the  lung  and  have 
its  exit  in  the  floor  of  the  pelvis. 
The  caliber  of  the  wound  is  narrow 
in  the  glandular  organs  of  the  ab- 
domen. The  entrance  and  exit 
wound  may  be  of  the  same  size;  in 
exceptional  cases  only  is  the  wound 
of  exit  lacerated.  In  grazing  shots  the 
borders  of  the  wound  are  sharp  and 
well  defined.  The  caliber  of  the 
wound  is  more  circumscribed  in  the 
pancreas  and  kidney  than  in  the 
spleen  or  liver.  The  abdominal 
organs  may  be  crushed  by  shots  at 
close  quarters.  Von  Doche  (Mili- 
taerarzt,  July,  1909). 

Such  a  diagnosis  is  further  strength- 
ened by  hematemesis  or  bloody  stools, 
the  former  tending  to  indicate  a 
lesion  of  the  stomach.  Death  occurs 
in  96  per  cent,  of  such  cases  if  un- 
operated. 

There  are  two  chief  mechanisms  by 
which  lesions  of  the  intestine  by  ab- 
dominal contusions  are  produced:  (1) 
Crushing  of  the  bowel  against  the  ver- 
tebral column,  and  (2)  bursting  of  a 
loop  of  gut.  The  former  is  the  more 
common,  the  dangerous  blows  being 
directed  anteroposteriorly  if  applied  in 
the  median  line,  or  obliquely  inward  if 
applied  laterally,  in  either  case  pressing 
the  bowel  forcibly  against  the  spine. 
Much  less  dangerous  are  blows  directed 
obliquely  outward  if  applied  to  the 
median  line,  or  those  directed  almost 
parallel  to  the  anterior  abdominal  wall. 
The  smaller  the  st-iking  surface  of  the 
agent  the  greater  the  risk  of  intestinal 
lesion,  the  parenchymatous  organs  being 
especially  involved  when  the  striking 
surface  is  large.  The  mucous  mem- 
brane gives  way  first,  then  the  muscular, 
and  lastly  the  serous  coat,  so  that  the 
resulting  wound  is  funnel-shaped  with 
the  base  directed  internally.  For  a 
lesion  to  be  produced  by  bursting,  the 
communication  of  the  intestinal  loop 
with  the  loops  above  and  below  must  be 
momentarily  intercepted  by  the  injuring 
force,  the  loop  must  be  distended  with 
fluid  or  gas,  and  the  striking  surface  is 
usually    large.     The    serous    coat    gives 


ABDOMINAL   INJURIES    (LAPLACE). 


109 


way  first,  and  the  wound  is  funnel- 
shaped  with  the  base  external.  The 
rupture  usually  occurs  at  the  summit  of 
the  loop.  C.  Dambrin  (Revue  de  chi- 
rurgie,  vol.  xxix,  No.  3,  p.  457,  1904). 

Case  of  traumatic  rupture  of  the 
intestine  by  indirect  violence  in  a  woman 
of  26  whose  previous  health  had  been 
good.  While  hurrying  into  her  house 
to  escape  a  thunder-storm  she  slipped 
and  fell,  striking  the  ground  upon  the 
right  buttock.  She  had  just  partaken  of 
a  hearty  supper.  No  immediate  alarm- 
ing symptoms  were  noticed.  She  was 
awakened  in  the  middle  of  the  night  by 
severe  abdominal  pains.  The  abdominal 
symptoms  rapidly  increased,  and  two 
days  after  the  fall  the  patient  was  in 
a  critical  condition.  The  temperature 
was  104.3°,  the  pulse  140.  There  was 
marked  tympany. 

Case    in   which,    on    opening   the    ab- 
domen, there  escaped  cloudy  fluid,  but 
no   gas.     On   separating   the    adhesions 
which    had     formed    about    the    great 
omentum    there    was    a    gush    of    fluid 
heavily    loaded    with    fibrinous    flakes. 
The  small  intestine  was  distended  and 
of  a  bluish-black  color.     A  small  per- 
foration was  discovered  on  the  convex 
surface    of    the    lower    portion    of    the 
jejunum.     This    was    sutured    into    the 
abdominal   wound.     The   abdomen  was 
drained.     The   shock   of   the   operation 
was  considerable,  but  on  the  second  day 
there    was    improvement.      The    fistula 
persisted.     Three  months  later,  the  fis- 
tula continuing  to  discharge,  the  patient 
had  become  alarmingly  weak  owing  to 
the  failure  in  assimilation  of  food,  all 
effort  to  heal  the  fistula  having  failed. 
A  second  operation  was  done,  the  fistula 
was  closed,   and  the   continuity   of  the 
gut  restored.     Recovery  was  rapid,  and 
in  the  next   few  months  she  gained  25 
pounds  in  weight.     E.  J.   Senn    (Amer. 
Jour.  Med.  Sciences,  June,  1904). 

The  effects  of  contusions  of  the  abdo- 
men upon  the  intestinal  ligaments,  upon 
the  mesocolon  and  the  mesentery,  have 
not  been  much  studied.  The  intestinal 
arteries  that  are  injured  in  lacerations 
of  the  mesentery  are  the  superior  and 
inferior  mesenteric  arteries  or  their 
branches.     A  wound  of  the   secondary 


branch  of  the  superior  mesentery  far 
from  the  intestine  does  not,  owing  to 
the  richness  of  the  anastomosis,  cause 
gangrene  of  the  intestine;  but,  if  the 
branches  are  cut  or  injured  near  the 
intestines,  gangrene  will  follow.  Here 
are  some  of  the  results  of  the  experi- 
ments: Section  of  the  superior  mesen- 
teric artery;  gangrene  of  a  long  portion 
of  the  small  intestine;  section  8  centim- 
eters in  length,  along  the  border  of  the 
mesentery  in  such  a  way  that  all  the 
recti  vessels  are  divid'^d  close  to  the 
intestine;  gangrene  of  the  intestine  for 

4  centimeters ;  incision  of  the  mesentery, 

5  centimeters  from  the  mesenteric  bor- 
der of  the  intestine;  placque  of  super- 
ficial gangrene  of  the  intestine;  incision 
8  centimeters  from  the  mesenteric  bor- 
der of  the  intestine;  intestine  is  not 
involved.  The  closer  these  lesions  are 
to  the  intestine,  the  more  serious  are 
their  consequences. 

These  anatomical  and  physiological 
notions  have  their  importance  in  thera- 
peutics;  in  fact,  early  death  from 
hemorrhage  is  inevitable  if  one  does  not 
intervene  surgically.  If,  perchance,  pa- 
tient should  survive  this  hemorrhage,  he 
soon  would  be  exposed  to  gangrene  of 
the  intestine  and  to  peritonitis.  Hence, 
early  laparotomy  is  indicated  in  these 
cases.  Every  time  the  tear  is  located 
near  the  intestine  an  enterectomy  of  the 
corresponding  intestinal  zone  is  indi- 
cated. If  it  is  parallel  to  the  axis  of  the 
mesentery  and  at  some  distance  from 
the  mesenteric  border  of  the  gut,  simple 
ligation  of  the  vessel  will  suffice.  Fur- 
ther, one  can  fix  an  omental  graft  upon 
the  intestine  so  as  to  assure  collateral 
circulation.  A.  Labastie  (Arch.  gen.  de 
chir.,  Jan.  25,  1908). 

Study  based  on  2500  cases  recorded 
in  various  hospitals.  It  has  been  recom- 
mended that  the  abdomen  should  be 
explored  in  all  cases  of  severe'  ab- 
dominal_  injury,  and  that  the  question 
of  diagnosis  may  be  left  until  the  parts 
have  been  actually  exposed  by  opera- 
tion. There  can  be  no  doubt  that  the 
exact  lesion  or  lesions  may  sometimes 
be  difficult  or  even  impossible  to  define, 
but  an  attempt  should  faithfully  be 
made  to  come  to  a  conclusion  before  the 


no 


ABDOMINAL   INJURIES    (LAPLACE). 


abdomen  is  opened;  an  operation  should 
not  be  done  "on  the  chance,"  but  all 
the  symptoms  carefully  noted  and 
weighed  after  a  S3^stematic  examination 
of  the  patient. 

If  it  is  possible  to  ascertain  the  exact 
part  of  the  body  struck  by  the  force 
which  caused  the  injury,  then  one  can 
make  an  approximate  guess  as  to  the 
organ  ruptured,  for  it  is  generally  lying 
beneath,  between  that  point  and  the 
spine,  and  incision  over  this  area  gives 
direct  access  to  the  damaged  structure. 
W.  H.  Battle  (Practitioner,  July,  1910). 

In  the  differential  diagnosis  of  ab- 
dominal contusion  the  greatest  feature 
for  an  early  recognition  of  the  existing 
conditions  is  whether  there  is  unilateral 
or  general  tension  of  the  abdommal 
wall,  unless  there  is  considerable  blood- 
suffusion  at  the  injured  place.  Aside 
from  the  reflex  tension  of  the  ab- 
dominal muscles,  a  slight,  but  distinct 
exacerbation  of  the  general  condition 
during  the  first  few  hours  following 
the  injury  is  a  point  of  import:mce. 
With  very  careful  observation,  three  or 
four  hours  may  be  allowed  to  elapse, 
but  even  then  there  is  the  possibility  of 
error.  Koerte  reported  a  case  where 
he  was  absolutely  certain  of  his  diag- 
nosis and  had  decided  to  operate ;  the 
patient,  however,  refused  operation  and 
made  a  smooth  recovery. 

In  the  most  favorable  cases,  where 
is  but  a  slight  tear,  the  mucous  mem- 
brane will  prolapse  and  occlude  the 
aperture.  Neighboring  loops  or  thi 
omentum  will  form  a  layer  over  the 
lesion  with  agglutination  or  adhesion, 
so  that  recovery  may  take  place.  If 
there  is  exudation  of  intestinal  contents, 
a  circumscribed,  encysted  abscess  may 
form  which  is  capable  of  resorption,  or 
secondary  perforation  into  the  intestine 
or  outward  may  occur ;  but  it  is  equally 
possible  that  pus  will  find  -the  danger- 
ous route  into  the  free  abdominal 
cavity. 

In  the  most  unfavorable  cases  there  is 
neither  occlusion  nor  abscess  formation  ; 
the  inflammation  will  rapidly  spread 
over  large  areas  or  over  the  entire 
peritoneum  and  cannot  be  checked.  As 
early   as   four  hours,   exudate   may  be 


found ;  likewise,  fibrinous  deposits  on 
the  various  loops.  The  more  or  less 
fulminating  course  is  not  only  depend- 
ent upon  the  quantity  of  the  exudate, 
but  also  on  its  infectious  nature.  This 
differs  in  the  various  sections  of  the 
gastrointestinal  tract,  as  has  been  sho'.vn 
by  Brunner,  and,  according  to  him,  the 
greatest  weight  attarhcs  to  '  phyrical 
factors  (variations  in  consistency) 
favoring  the  propagation  oT  infectious 
material.  For  this  reason  h;  considers 
lacerations  of  the  small  intestine  more 
dangerous  than  those  of  the  large  in- 
testine, as  in  the  former  the  quantity  of 
bacteria  increases  toward  the  cecum. 

Statistics  show  the  rarity  of  cases  in 
which  the  most  favorable  course,  as 
depicted  above,  takes  place.  Of  160 
cases  of  subcutaneous  inte:tinal  rui- 
ture  in  which  the  expectant  treatment 
was  instituted,  149  died;  of  tho  11  which 
recovered,  10  had  to  be  operated  dur- 
ing treatment  for  fecal  abscesses  and 
fistulse.  These  figures  furnish,  in  the 
writer's  opinion,  clear  and  distinct 
proof  for  the  insufficiency  of  expectant 
treatment,  which,  indeed,  should  be 
totally  discarded.  Enderlen  (Post- 
Graduate,  July,  1911). 

Lesions  of  the  Stomach. — Blows 
seldom  cause  rupture  of  the  stomach, 
the  elasticity  of  the  organ,  even  when 
containing  liquid  or  semiliquid  ma- 
terial, being  such  as  to  cause  it  to 
escape  injury  under  sudden  impact 
or  great  pressure.  It  is  also  pro- 
tected by  the  lower  ribs,  the  liver, 
and  the  intestines.  Nevertheless,  this 
organ  is  occasionally  involved  in 
traumatism  affecting  other  abdom- 
inal viscera.  In  the  majority  of  cases 
the  rent  is  found  near  the  pyloric 
orifice,  but  the  greater  curvature  may 
be  the  seat  of  the  lesion,  while  the 
entire  organ  is  occasionall}^  torn  from 
end  to  end.  In  the  latter  case, 
however,  death  ensues  almost  imme- 
diately in  practically  all  cases.  Pres- 
sure  during   lavage   of   the   stomach 


ABDOMINAL   INJURIES    (LAPLACE). 


Ill 


ma}'  also  cause  laceration  of  the 
mucous  membrane. 

In  the  case  of  incomplete  tears 
there  ma}'  l)e  hematemesis  and  severe 
localized  pain  resembling'  that  of  gas- 
tric ulcer, — gnawing'  and  burning'  in 
cliaracter.  This  is  followed  l^y  local- 
ized inrtammation  Avith  tendency  to 
the  formation  of  adhesions.  Hemor- 
rhage between  the  coats  of  the  stom- 
ach may  also  occur  in  incomplete 
tears,  a  cyst-like  pocket  being  formed. 

Molent  pressure  upon  the  stomacli 
may  cause  it  to  be  crushed  ag-ainst 
the  spinal  column,  and  the  mucous 
surfaces  be  lacerated  by  interpressure 
of  the  anterior  and  posterior  walls  of 
the  org-an.  In  such  a  case  a  marked 
lesion  necessarily  folloAvs,  g'iving  rise 
to  copious  hematemesis. 

Rupture  of  the  stomach  implicates 
the  peritoneal  coat  in  the  majority  of 
cases,  the  elasticity  of  the  peritoneal 
investment  being  less  than  that  of 
the  two  internal  coats :  muscular  and 
mucous.  The  contents  of  the  stom- 
ach, or  a  portion  of  them,  escape 
into  the  peritoneal  cavity  and  cause 
severe  suffering  and  shock,  followed 
promptly  by  death  or  septic  peritoni- 
tis. Bryant  teaches  that  a  ruptured 
intestine  is  probably  present,  though 
this  is  not  certain,  when,  after  a 
diffuse  injury  to  the  abdomen  or  a 
severe  local  injury  as  the  immediate 
result  of  the  accident,  there  is  little 
collapse,  and  when  vomiting  soon  be- 
comes a  prominent  and  persistent 
symptom,  with  lasting  local  pain  and 
great  thirst,  with  or  without  abdom- 
inal enlargement. 

According'  to  Gluzinski,  two  signs 
which  enable  the  physician  to  diag- 
nose the  occurrence  of  intestinal  per- 
foration before  peritonitis  has  had 
tim-e  to  manifest  itself:     1,  distinct- 


ness of  the  murmurs  of  the  heart  and 
respiration  during  auscultation  of  the 
al)domen,  due  to  the  presence  of  in- 
testinal gases  in  the  peritoneal  cavity. 
2,  change  in  the  pulse,  which,  at  the 
moment  of  perforation,  becomes  accel- 
erated, to  slacken  some  hours  later, 
owing  to  the  absorption  of  putrid 
gases  acting  as  cardiac  poison. 

Four  symptoms  of  internal  abdominal 
injury  are  especially  important  and 
trustworthy:  1.  Permanent  and  pro- 
gressive feebleness  and  frequency  of 
the  pulse,  especially  if  combined  with 
pallor,  a  general  state  of  anxiety,  of 
depression,  or  of  delirious  excitement. 
Abdominal  tenderness  soon  after  in- 
jury or  after  the  onset  of  acute  symp- 
toms may  indicate  hemorrhage  rather 
than  inflammation.  2.  Loss  of  liver 
dullness  with  progressive  gaseous 
distention  of  the  abdomen,  or  ten- 
derness and  resistance  of  the  parietes. 
This  indicates  perforation  of  the 
gastrointestinal  tract.  3.  Limited 
dullness  on  percussion  without  dis- 
tention is  also  produced  in  some 
cases  of  perforation.  4.  Shifting  dull- 
ness in  one  or  both  flanks  as  is  observed 
in  cases  of  ruptured  bladder  or  large 
hemorrhage.  C.  A.  Ballance  (Lancet, 
Oct.  29,  1904). 

Case  in  which  laparotomy,  after  a 
severe  contusion  of  the  abdomen,  re- 
vealed an  extensive  tear  of  the  mesen- 
tery as  the  only  resultant  injury.  Gan- 
grene of  the  ileum  had  commenced  as  a 
result  of  the  laceration  of  the  nutrient 
A'essels.  Reinecke  (Miinch.  med.  Woch., 
Sept.  8,  1908). 

Lesions  of  the  Liver. — The  liver, 
owing  to  its  friable  nature,  its  size, 
and  its  anatomical  position,  is  the 
organ  most  frequently  injured,  be- 
cause indirect  concussion  may  cause 
a  profound  lesion.  A  fall  from  a 
great  height  into  water  may  thus 
cause  a  gaping  rent  of  the  capsule 
and  parenchyma  and  open  a  large 
number  of  vessels.  Severe  and  sud- 
den   blows    of    any    kind,    especially 


112 


ABDOMINAL   INJURIES    (LAPLACE). 


those  involving  much  surface,  over 
the  abdominal  wall  may  thus  cause 
injury  to  this  organ.  Again,  its  soft- 
ness, which  may  be  increased  by 
hypertrophy,  cause  it  to  yield  readily 
to  the  crushing  produced  by  carriage- 
wheels,  car-bumpers,  etc. 

The  severity  of  all  the  general 
symptoms  is  usually  increased.  The 
pain,  when  the  liver  is  seriously  in- 
jured, is  peculiar;  it  radiates  from  the 
right  hypochondrium  to  the  waist, 
the  scrobiculus  cordis,  or  the  scapular 
region.  The  respiration  is  generally 
embarrassed;  there  is  marked  shock. 
Examination  of  the  feces  may  show 
the  absence  of  bile,  especially  if  the 
bile-duct  is  ruptured :  an  occasional 
complication.  The  dissemination  of 
bile  in  the  system  causes  itching  and, 
after  a  time,  jaundice.  The  escape 
of  bile  into  the  peritoneal  cavity  may 
not  give  rise  to  peritonitis,  however, 
this  fluid  being  aseptic.  A  serous 
exudate  may  result  from  the  irrita- 
tion caused  by  its  presence,  forming 
a  composite  fluid  which  may  be  re- 
tained in  the  peritoneal  cavity  a  con- 
siderable time. 

Rupture  of  the  liver  is  an  extremely 
fatal  accident,  and  the  symptoms  which 
ensue  are  usually  marked  and  serious. 
Shock  is  present,  frequently  passing 
into  collapse  and  death.  Short  of  this 
there  are  vomiting,  rapid  pulse  and  res- 
piration, pallor,  etc.  In  this  accident 
rigidity  of  the  abdominal  wall  is  very 
evident,  so  that  it  may  appear  board- 
like. Tenderness  becomes  localized  to 
the  hepatic  region,  and  there  is  shifting 
dullness  in  the  flanks  with  the  ordinary 
symptoms  of  loss  of  blood,  according  to 
the  amount  of  it  which  is  effused;  the 
man  becoming  restless  with  a  rapid, 
weak  pulse,  sighing  respiration,  and 
what  is  called  "air  hunger."  Jaundice 
may  be  a  late  symptom  and  is  there- 
fore of  no  use  in  the  early  diagnosis, 
which  is  so*  very  important. 


There  is,  as  might  be  expected,  much 
variation  in  the  size  of  the  rupture, 
which  is  usually  on  the  convex  surface 
of  the  right  lobe ;  the  combined  statis- 
tics of  Mayer  and  Ogston  give  3  right 
lobe  to  1  left  lobe  as  the  proportions. 

Shock  in  this  injury  may  not  be 
evident  when  the  patient  first  comes 
under  observation.  When  leaving  the 
Royal  Free  Hospital  some  years  ago  the 
writer  saw  a  woman  of  59  brought  in, 
who  had  been  run  over  in  the  street  a 
few  minutes  earlier.  She  was  excited, 
and  resented  examination.  There  were 
no  marks  on  the  abdomen,  no  dullness 
in  the  flanks,  or  rigidity  of  the  muscles. 
It  was  difficult  to  induce  her  to  remain 
in  the  hospital,  yet  three  hours  later  the 
abdomen  was  full  of  blood,  and  she  did 
not  survive  operation  to  arrest  the 
bleeding  for  very  long.  The  liver  was 
extensively  torn,  and  the  kidney  showed 
a  recent  laceration ;  there  were  other 
injuries  also.  W.  H.  Battle  (Practi- 
tioner, July,  1910). 

The  most  reliable  symptom  is  the 
defense  inusculaire  emphasized  by  Hart- 
mann  and  Trendelenburg.  Rigidity  is 
not  the  proper  term  for  this  condition, 
for  rigidity  rather  denotes  a  tetanic 
state  of  the  abdominal  muscles,  whether 
stimulated  by  pressure  of  the  hand  or 
not.  It  is  not  marked,  except  in  the 
gravest  cases,  shortly  after  injury,  but 
develops  in  the  following  few  hours 
from  irritation  of  the  peritoneum  by 
the  hemorrhage  of  intestinal  contents 
from  rupture  of  the  intestines.  It  was 
especially  mentioned  twenty-four  times 
in  the  44  cases,  and  in  the  remainder 
other  signs,  notably  those  of  internal 
hemorrhage,  were  so  marked  that  it 
was  not  noted  in  the  history.  Never- 
theless, it  is  not  an  infallible  symptom, 
as  proved  by  2  cases  related  by  Baum. 
Riebel  (Quarterly  Bull.  N.  W.  Univ. 
Med.  School,  Sept.,  1910). 

A  rent  is  probable  after  a  severe 
injury  if  there  is  collapse,  if  the  pulse 
becomes  more  rapid  and  small,  if  the 
patient  shows  signs  of  exsanguinity, 
if  the  area  of  liver-dullness  on  per- 
cussion   is    increased,    and    if    pain 


ABDOMINAL   INJURIES    (LAPLACE). 


113 


radiating-  to  the  scapular  region  is 
complained  of.  Severe  injury  may 
exist,  however,  without  these  indica- 
tions. 

The  liver  is  injured  with  greater  fre- 
quency than  any  other  abdominal  viscus. 
Of  365  cases  of  subcutaneous  injuries 
of  solid  viscera  the  liver  was  injured  in 
189.  The  spleen,  kidney,  and  pancreas 
combined  in  but  179.  The  factors  which 
favor  a  high  percentage  of  injury  are : 
(1)  It  lies  wedged  between  the  ribs  and 
vertebral  column,  and  (2)  it  is  very 
heavy  and  elastic  and  only  slightly 
movable.  It  is  nine  times  as  heavy  as 
the  spleen  and  ten  times  as  heavy  as  the 
kidney.  Furthermore,  the  physiological 
function  of  digestion  renders  it  more 
liable  to  injurj-,  since  the  gland  is  en- 
gorged with  blood.  Again  the  organ 
is  particularly  Hable  to  disease.  Alco- 
holism, tuberculosis,  malarial  lesions, 
new  growths  and  the  production  of 
fibrous  tissue  rendering  it  even  more 
friable  than  in  its  normal  condition. 
B.  T.  Tilton  (Annals  of  Surg.,  Jan., 
1905). 

Case  in  which  a  man,  19  years  old, 
suffered  from  a  contusion,  with  possible 
rupture  of  the  liver.  Four  days  later 
jaundice  appeared  on  the  sclerse  and 
biliary  coloring  matters  in  the  urine. 
The  jaundice  spread  thence  over  the 
entire  skin  of  the  body,  the  urine 
became  dark  brown,  and  from  the 
seventh  day  on  the  patient  suffered  from 
extremely  severe  attacks  of  colic.  At 
the  beginning  of  the  third  week  the 
area  of  liver  dullness  was  markedly 
small.  The  attacks  of  colic  were  as- 
cribed to  adhesions,  and  finally  lapa- 
rotomy was  performed  with  a  view  to 
their  relief.  About  4  liters  of  bile- 
stained  ascitic  fluid  escaped  when  the 
peritoneal  cavity  was  opened,  numerous 
adhesions  were  broken  up,  and  a  fibrin- 
ous exudate  was  wiped  away  from  the 
surface  of  the  intestines.  Palpation  of 
the  liver  revealed  that  that  organ  was 
very  atrophic,  but  no  operative  measures 
were  directed  to  its  relief,  and  the 
wound  w^as  closed.  At  first  little 
change  was  produced  in  the  condition 
of    the    patient.      Ten    days    after    the 


operation  an  abscess  was  opened  in  the 
cicatrix,  and  then  he  began  to  improve. 
The  area  of  liver  dullness  gradually 
increased  until  it  finally  reached  the  bor^ 
der  of  the  ribs  in  the  right  mammillary 
area,  but  its  lower  margin  could  not  be 
felt  on  palpation.  The  general  health 
of  the  patient  had  also  become  very 
good.  Mekus  (Miinch.  med.  Woch., 
Jan.  8,  1907). 

History  of  8  cases  of  injury  of  the 
liver  in  which  an  operation  was  per- 
formed in  less  than  four  hours  in  all 
but  one,  in  which  the  interval  was  ten 
hours.  They  emphasized  the  advantage 
of  suturing  the  wound  in  the  liver  when- 
ever it  is  at  all  possible.  The  writer 
sutures  through  a  tampon  to  prevent 
bleeding  later.  He  has  recently  ex- 
amined 3  of  the  patients  after  an 
interval  of  from  several  months  to  two 
and  a  quarter  years,  and  found  them 
entirely  well  and  free  from  disturbances 
of  any  kind.  Noetzel  (Beitrage  z.  klin. 
Chir.,  xlviii,  Nu.  2,  1906) . 

Case  of  subcutaneous  injury  to  the 
right  lobe  of  the  liver.  The  patient  had 
fallen  from  his  horse  and  his  abdomen 
had  borne  the  weight  of  the  horse  and 
of  the  saddle.  Diagnosis  of  internal 
hemorrhage  was  made.  After  a  minute 
exploration  of  the  abdominal  cavity,  a 
bleeding  wound  of  the  right  lobe  of  the 
liver  was  seen.  The  hemorrhage  was 
stopped  by  tamponade ;  the  patient  re- 
covered. The  diagnosis  is  to  be  made 
only  after  the  abdominal  wall  has  been 
opened,  and  then  it  is  made  by  seeing 
the  seat  of  hemorrhage. 

We  are  still  in  doubt  as  to  which  way 
is  better,  to  suture  these  wounds  of  the 
liver,  or  to  pack  them.  The  author  pre- 
fers packing.  He  thinks  it  is  more 
rapid,  less  difficult,  and  more  reliable. 
The  liver  must  be  compressed  from 
below  up  toward  the  diaphragm.  Only 
iodoform  gauze  should  be  used.  Yon 
Kippel  (Arch.  gen.  de  chir.,  Dec,  1907). 

Seven  cases  of  injury  of  the  liver  in 
which  surgical  treatment  was  success- 
ful in  3.  The  injuries  in  the  cases  with 
a  favorable  outcome  were :  A  bullet 
wound,  a  kick  from  a  horse,  and  injury 
from  being  run  over.    The  others  were 


1— s 


114 


ABDOMINAL   INJURIES    (LAPLACE). 


very  serious  contusions  with  other 
injuries.  Rigidity  extended  over  the 
entire  abdomen  in  every  case,  and  the 
pain  on  palpation  was  also  diffuse, 
although  more  pronounced  on  the  right 
side.  Tamponing  alone  arrested  the 
hemorrhage  in  the  three  favorable 
cases.  The  pulse  gave  no  signs  of  the 
internal  bleeding,  being  relatively  good 
even  in  the  most  rapidly  fatal  cases.  In 
one  instance  the  gauze  tampon  answered 
a  double  purpose,  draining  a  pus  pocket 
that  developed  between  the  diaphragm 
and  the  liver.  The  writer's  experience 
confirms  the  value  of  tamponing  as  the 
best,  safest,  most  rapid  and  effectual 
method  of  arresting  hemorrhage  in  case 
of  rupture  of  the  liver,  although  a 
suture  may  be  advisable  for  a  smooth 
and  conveniently  located  stab  wound. 
Dencks  (Deut.  Zeit.  f.  Chir.,  Ixxxii, 
Nu.  4-6,  1907). 

In  the  diagnosis  of  injury  of  the  liver 
bradycardia  is  a  suggestive  sign.  In 
one  case  the  liver  had  been  ruptured 
by  the  kick  of  a  horse  and  the  pulse 
was  only  48.  In  the  other  case  the 
liver  had  been  sutured  and  the  pulse 
was  52.  Several  writers  have  men- 
tioned bradycardia  with  injury  of  the 
liver,  and  ascribe  diagnostic  importance 
to  it.  The  writer  experimented  on 
animals  to  determine  the  influence  on 
the  pulse  of  injury  of  liver  and  spleen. 
The  results  with  20  animals  showed 
that  bradycardia  is  a  characteristic 
symptom  of  injury  of  the  liver,  but  that 
its  absence  does  not  exclude  injury  of 
this  organ.  Finsterer  (Archiv  f.  klin. 
Chir.,  Bd.  xcv,  Nu.  2,  1911). 

In  8  cases  of  rupture  of  the  liver 
operated  in  the  last  five  years,  the 
writer  noted  that  in  2  of  the  cases  the 
fundus  of  the  eye  showed  changes  re- 
calling those  of  albuminuric  retinitis. 
These  patients  were  men  of  18  and  30 
with  severe  contusion  of  the  liver 
region  and  rupture  of  the  liver  requir- 
ing suture.  In  1  case  the  changes  in 
the  fundus  had  subsided  by  the  end  of 
the  second  day.  Tietze  (Archiv  f.  klin. 
Chir.,  Bd.  xcv,  Nu.  2,  1911). 

Lesions     of     the     Gall-bladder     or 
Biliary  Ducts, — Blows  and  other  con- 


ditions capable  of  causing  hepatic 
rents  sometimes  implicate  these 
organs  in  the  lesion.  There  may  be 
severe  pain  in  the  right  hypochon- 
drium  if  a  rupture  exists,  vomiting 
of  food  and  bile,  and  icterus.  The 
urine  is  usually  dark-mahogany  and 
the  stools  ash-gray  in  color.  Tender- 
ness over  the  hepatic  region  is  usually 
marked.  The  intensity  of  the  symp- 
toms depend  to  a  degree  upon  the 
quantity  of  bile  voided  into  the 
abdominal  cavity ;  but,  this  secretion 
being  aseptic,  peritonitis  only  occurs 
as  a  complication  when  the  perito- 
neum is  itself  implicated  in  the  trau- 
matism, or  when  the  lesion  is  at  the 
junction  of  the  biliary  tract  and  the 
intestinal  canal,  the  latter  in  that  case 
acting  as  a  source  of  infection. 

Escape  of  venous  blood  with  or  with- 
out   bile,    particularly    in    stab    wounds 
over  the  region  of  the  liver,  is  a  very 
important  sign.    Hepatic  injuries  usually 
cause  pain  to  ra:diate  to  the  right  shoul- 
der.    Inasmuch   as   there    is   also   local 
pain  on  respiration,  the  chest  does  move 
as   much   on   the   right  as   on  the  left. 
This  may  lead  to  a  misconstruction  of 
the    diagnosis,    for    it    suggests    to    the 
casual    observer   thoracic    injury.      The 
blood  gravitates  into  the  right  iliac  fossa 
and    may    give    well-marked    dullness. 
Disappearance  of  liver  dullness  is  due  to 
beginning  tympanites  and  is  therefore 
not     of     great     diagnostic     importance. 
Jaundice    is    occasionally    present,    but 
usually  does  not  appear  until  the  second 
or    fourth    day.      Ludwig    found    it   24 
times  in  267  cases.     Its  presence  usually 
signifies  injuries  of  the  bile-duct.     B. 
T.    Tilton     (Annals    of    Surg.,    Jan., 
1905). 
Lesions  of  the  Spleen. — The  causes 
of  injury  to  this  organ  are  the  same 
as    those    of   the    liver.      Rents^    san- 
guineous     infiltration,      and      partial 
crushing    are    the    lesions    most    fre- 
quently   observed.      Enlargement    of 
spleen   through   a    malarial    cachexia 


ABDOMINAL   INJURIES    (LAPLACE). 


115 


renders  it  susceptible  to  lesions 
which  traumatism  would  not  give 
rise  to  were  it  in  its  normal  state. 

In  extensive  lesions  copious  hemor- 
rhai^e  usually  takes  place  and  death 
rapidly  follows.  If  the  lesion  present 
is  less  severe,  however,  and  the  hemor- 
rhage be  moderate,  there  is  tendency 
to  collapse,  increasing  pallor,  and  a 
feeling  of  suffocation.  The  latter 
symptom  and  severe  radiating  pain 
in  the  region  of  the  spleen  are  gener- 
ally present,  besides  the  signs  pecul- 
iar to  all  abdominal  injuries.  If  the 
patient  survives  sufficiently  long  the 
immediate  effects  of  the  traumatism, 
peritonitis  or' abscess  and  other  com- 
plications frequently  result.  Severe 
local  pain  generally  continues  for 
some  time,  and  chills  are  not  infre- 
quent. Percussion  shows  the  organ 
to  be  more  or  less  enlarged. 

According  to  Trendelenburg,  vomit- 
ing is  a  most  important  guide  in  the 
diagnosis  of  rupture  of  the  spleen ;  in 
simple  contusion  of  the  alimentary 
tract  it  seldom  if  ever  occurs. 

History  of  6  patients  whose  spleens 
were  removed  on  account  of  the  injury 
of  the  organ.  There  was  no  symptom 
specially  characteristic  of  such  injury, 
though  signs  of  irritation  of  the  peri- 
toneum from  effusion  of  blood  de- 
manded prompt  intervention.  Severe 
pain  at  the  point  of  injury  invari- 
ably accompanied  serious  damage  with- 
in, however.  In  one  of  the  cases 
the  early  intraperitoneal  hemorrhage 
stopped  spontaneously,  but  commenced 
again  the  third  da}^  requiring  operative 
measures.  Noetzel  (Beitrage  z.  klin. 
Chir.,  xlviii,  Nu.  2,  1906). 

Case  of  a  girl  of  4  who  had  been  run 
■over  by  a  cab.  The  symptoms  of  shock 
subsided,  the  pulse  became  slower  and 
fuller,  and  not  until  after  seven  hours 
were  signs  of  internal  hemorrhage 
observed.  The  abdominal  walls  did  not 
become  rigid  until  ten  hours  after  the 


accident ;  the  child  had  vomited  blood 
twice  during  the  interim.  The  abdomen 
was  opened  at  about  the  twentieth  hour 
and  the  ruptured  spleen  removed  with 
the  apparent  complete  recovery.  The 
lower  pole  of  the  organ  had  been  partly 
torn  off.  In  a  case  in  which  the  symp- 
toms indicated  rupture  of  the  spleen  th? 
exploratory  laparotomy  revealed  merely 
a  few  small  subserous  hemorrhages,  and 
the  abdomen  was  sutured  without  fur- 
ther intervention,  followed  by  the  com- 
plete recovery.  Georgi  (Miinch.  med. 
Woch.,  liii,  Nu.  15,  1906). 

A  healthy  spleen  is  seldom  injured; 
the  organ  is  usually  already  enlarged  by 
some  pathologic  process  or  infection. 
Slight  injury  may  cause  only  an  absorb- 
able hematoma,  or,  if  infected,  an 
abscess  and  adhesions  which  maj'  dis- 
charge through  adjacent  hollow  organs. 
Such  outcome,  however,  is  rare ;  the 
tear  is  usually  through  the  envelope 
and  rapid  hemorrhage,  calling  for 
quick  surgical  intervention,  occurs. 
E.  J.  Senn  (Jour.  Amer.  Med.  Assoc, 
Mar.  23,   1907). 

Case  of  rupture  of  the  spleen.  The 
patient  had  received  a  violent  trauma- 
tism in  the  left  hypochondriac  region, 
and  had  a  few  fainting  spells.  There 
was  abdominal  distention  and  tender- 
ness. An  exploratory  laparotomy  having 
shown  serious  intra-abdominal  hemor- 
rhage, the  spleen  was  found  torn 
and  was  extirpated.  Raoul  Baudet 
(Medecin  Praticien,  1907;  Surg.,  Gynec. 
and  Obstet.,  July,  1908). 

The  symptoms  of  traumatic  rupture 
of  the  spleen  are  essentially  those  of 
internal  hemorrhage,  and  the  diagnosis 
is  usually  not  made  tmtil  after  ab- 
dominal section.  The  symptoms  are 
obscure  so  far  as  enabling  the  distinc- 
tion whether  the  spleen  or  some  other 
abdominal  viscera  is  ruptured.  How- 
ever, there  should  be  no  difficulty  in 
diagnosticating  the  existence  of  hemor- 
rhage into  the  abdominal  cavity,  and, 
when  this  condition  is  recognized,  ab- 
dominal section  is  indicated.  The 
incision  should  be  made  over  the  region 
of  greatest  dullness,  if  this  can  be 
determined.    If  percussion  elicits  a  note 


116 


ABDOMINAL   INJURIES    (LAPLACE). 


of  higher  pitch  in  one  flank  than  in  the 
other,  a  valuable  hint  as  to  the  source 
of  hemorrhage  has  been  obtained. 
Should  the  hemorrhage  be  sufficiently 
severe  to  give  a  percussion  note  of  equal 
dullness  in  all  regions  the  indication  is 
to  make  the  incision  in  the  middle  line. 
The  treatment  is  essentially  surgical,  the 
object  being  the  control  of  hemorrhage, 
and  all  authorities  are  agreed  that  this 
end  is  most  certainly  accomplished  by 
splenectomy.  The  mortality  following 
removal  of  the  healthy  spleen  for  rup- 
ture is  about  40  per  cent.,  wrhereas  that 
of  non-operative  treatment  is  probably 
100  per  cent.  Watkins  (Med.  Rec, 
Mar.  14,  1908). 

Lesions     of     the     Kidneys.  —  The 

kidney  is  firmly  held  in  place  by  its 
attachments,  while  its  consistence  is 
such  as  to  preclude  elasticity.  Hence, 
a  blow  or  undue  pressure  may  cause 
rupture.  All  the  causes  of  injury 
that  may  take  part  in  the  production 
of  lesions  elsewhere  may  also  induce 
renal  lesions,  which  may  consist  of 
contusion,  rupture,  or  laceration. 

Study  of  5  personal  cases  and  of  660 
cases  gathered  from  literature.  The 
causes  of  rupture  were  varying,  mus- 
cular action  causing  10  per  cent.  The 
author  was  struck  by  the  slight  force 
necessary  for  rupture  to  take  place. 
A  blow  over  the  front  of  the  abdomen 
with  the  patient  on  his  back  was  one  of 
the  causes  of  rupture.  The  kidney  was 
never  ruptured  on  one  side  with  an  ac- 
companying injury  to  an  organ  on  the 
opposite  side.  Intraperitoneal  symp- 
toms were  usually  due  to  rupture  of  the 
peritoneum.  Tumor  formation  occurred 
in  143  cases.  Hemorrhage  was  the  fre- 
quent cause  of  death.  In  all  the  cases 
there  was  a  striking  absence  of  injury 
to  the  omentum  or  the  intestine. 

Indications  for  operation  :  (1)  Marked 
and  persistent  hemorrhage ;  (2)  pres- 
ence of  a  rapidly  increasing  tumor  or 
area  of  dullness  in  the  loin;  (3)  de- 
velopment of  a  tumor  in  the  loin  ten 
days  or  more  aiter  injury;  (4)  imme- 
diate operation  when  there  are  signs  of 
free    fluid    in    the    abdominal    cavity; 


peritonitis  or  other  peritoneal  injuries. 
Watson  (Trans.  Amer.  Assoc,  of 
Genito-Urin.  Surg. ;  Amer.  Med.,  May 
30,  1903). 

The  kidneys  are  not  properly  ab- 
dominal organs,  being  extraperitoneal, 
but  their  injuries  are  comparatively  fre- 
quent, especially  in  young  males,  owing 
to  their  greater  exposure.  The  mechan- 
ism is  usually  a  bending  or  fracture  of 
the  lower  ribs.  One  cause  of  the  infre- 
quency  of  the  accident  in  women  may 
be  the  mode  of  dress,  the  corset  pro- 
tecting the  organ,  though  the  greater 
thickness  of  tissues  and  the  wider 
spread  of  the  iliac  crests  are  also  sug- 
gested as  factors  by  Kuster.  E.  J.  Senn 
(Jour.  Amer.  Med.  Assoc,  Mar.  23, 
1907). 

Case  in  which  the  patient  was  kicked 
in  the  kidney  region  by  a  horse.  The 
rupture  occurred  at  the  farthest  point 
of  the  organ,  the  kidney  having  probably 
been  dashed  against  the  spine.  Suarez 
(Annales  d.  Mai.  d.  Org.  Gen.-Urin., 
xxiv,  No.  17,  1907). 

In  the  rapid  recent  increase  in  the 
number  of  reported  cases,  there  is 
reason  to  believe  that  subparietal  rup- 
ture of  the  kidney  is  more  frequent 
than  the  literature  would  lead  one  to 
believe.  Shock,  injury  to  other  organs, 
and  external  evidence  of  trauma  are 
frequently  absent.  A  history  of  an 
abdominal  contusion,  followed  by  rigid- 
ity and  hematuria,  is  sufficient  data  to 
lead  to  an  exposure  of  the  organ. 
Slight  lesions  and  complete  rupture  of 
the  kidney  cannot  be  differentiated  by 
clinical  signs  or  symptoms.  Proof  that 
there  is  an  absence  of  serious  rupture  is 
tailed  for  before  instituting  the  so- 
called  expectant  treatment.  Nephrec- 
tomy should  be  reserved  for  very  ex- 
tensive disintegration  of  the  organ. 
Conservative  treatment,  preferably  by 
suture,  is  indicated  in  the  majority  of 
cases.  Connell  (Jour.  Amer.  Med. 
Assoc,  March  25,  1911). 

Besides  the  symptoms  common'  to 
severe  abdominal  traumatism  there 
may  be  increased  pain  in  the  lumbar 
region  with  radiations  in  the  direc- 
tion of  the  pubis  and  rigidity  of  the 


ABDOMINAL   INJURIES    (LAPLACE). 


u; 


muscles.  Dullness  on  percussion  is 
sometimes  elicited.  Anuria  may  also 
occur,  but  this  is  not  a  characteristic 
sign.  Hematuria  is  an  important  in- 
dication of  renal  leceration,  however, 
although  it  may  not  present  itself  at 
once ;  it  may  be  followed  by  the  ap- 
pearance of  pus.  The  catheter  should 
be  used  in  these.  Retraction  of  the 
testicles  is  also  said  to  occur  (Rayer). 
The  ureter  is  very  rarely  involved; 
when  it  is,  the  symptoms  are  not 
modified.  Enlargement  of  the  lumbar 
and  hypochondriac  regions  is  present 
in  the  majority  of  severe  cases,  but 
may  supervene  late  in  the  history  of 
the  case. 

Thanks  to  the  compensatory  work 
of  the  uninjured  kidney,  the  mortality 
of  renal  lesions  is  not  so  marked  as 
when  other  abdominal  organs  are 
injured. 

Even  severe  wounds  have  been 
known  to  heal.  If  large  renal  vessels 
are  torn,  marked  lividity  occurs,  the 
patient  rapidly  becoming  exsanguine. 
Death  may  thus  follow  very  soon. 
Involvement  of  the  peritoneum  in 
the  injury  is  promptly  followed  by 
peritonitis,  the  signs  of  this  affection 
appearing  a  few  hours  after  the 
receipt  of  the  injury.  Sepsis  is  not 
an  infrequent  complication  in  un- 
operated  cases. 

Case  of  a  boy,  aged  16  years,  who  had 
fallen  a  distance  of  2  meters  during 
play,  striking  his  back.  Pain  over  the 
kidneys  developed,  but  not  sufficient  to 
force  him  to  stay  in  bed  until  the  tenth 
day,  when  he  began  to  vomit  and  de- 
velop an  intense  diarrhea.  He  bled 
from  the  nose  and  gums,  and  numerous 
petechiae  appeared  over  arms  and  legs. 
On  the  fifteenth  day  he  voided  bloody 
urine.  The  flanks  were  dull,  the  abdo- 
men distended  and  tympanitic.  Rectal 
examination  showed  a  mass  behind  the 
bladder.     Four   weeks    later   a    second 


purpuric  eruption  appeared  all  over  the 
body.  The  urine  was  still  bloody,  and 
an  ascitic  accumulation  was  noted  with- 
in the  abdominal  cavity.  The  red  cor- 
puscles were  reduced  to  3,200,000;  there 
were  334,000  hemoblasts;  the  blood  did 
not  clot  nearly  as  readily  as  normally, 
and  numerous  myelocytes  were  present. 
Complete  recovery  ultimately  resulted. 
E.  Lenoble  (Arch,  des  mal.  du  ccEur, 
i,  475,  1906). 

Two  cases  in  which  both  patients  fell 
on  the  loin,  the  one  falling  on  the  edge 
of  a  stair,  the  other  on  the  edge  of  a 
pail.  In  both  cases  blood  was  present 
in  the  urine  immediately  after  the  acci- 
dent and  the  ruptured  kidney  could  be 
felt  by  palpation.  In  both  cases  it 
extended  round  the  abdomen  toward  the 
umbilicus  and  was  tender  to  touch,  the 
swelling  being  clearly  behind  the  peri- 
toneum. Andrew  (Lancet,  Jan.  26, 
1907). 

Case  of  a  man  who  was  under  treat- 
ment for  about  three  weeks  with  the 
clinical  diagnosis  of  contusion  of  the 
right  kidney,  hemothorax  on  the  left 
side,  and  possible  injury  to  the  pancreas. 
Autopsy  showed  that  there  had  been  a 
total  rupture  of  the  left  lobe  of  the 
liver,  which  was  in  the  process  of  spon- 
taneous healing.  Chiari  (Berl.  klin. 
Woch.,  Sept.  7,  1908). 

In  complete  subparietal  rupture  of  the 
kidney  the  patient  will,  as  a  rule,  give 
a  history  of  having  received  a  severe 
blow  in  the  side.  The  examination  re- 
veals a  tumor  in  the  loin.  There  is, 
as  a  rule,  hematuria.  The  patient  is  in 
a  state  of  profound  shock.  These 
symptoms,  with  evidences  of  internal 
hemorrhage,  should  lead  one  to  treat 
the  patient  for  rupture  of  the  kidney. 
Prognosis  depends  upon  the  delay  in 
applying  the  proper  treatment.  The 
primary  mortality  is  due  to  hemorrhage, 
while  secondary  deaths  are  caused  by 
infection,  which  may  be  hematogenous 
or  ascending  in  origin.  The  mortality 
of  all  cases  of  subparietal  ruptures  of 
the  kidney  has  been  estimated  at  from 
32  to  92  per  cent.  Bugbee  (Med. 
Record,  Nov.  5,  1910). 

Owing  to  the  rapid  recent  increase  in 
the  number  of  reported  cases  there  is 


118 


ABDOMINAL  INJURIES    (LAPLACE). 


reason  to  believe  that  subparietal  rup- 
ture of  the  kidney  is  more  frequent  than 
the  literature  would  lead  one  to  believe. 
Shock,  injury  to  other  organs,  and  ex- 
ternal evidence  of  trauma  are  fre- 
quently absent.  A  history  of  an  ab- 
dominal contusion,  followed  by  rigidity 
and  hematuria,  is  sufficient  data  to  lead 
to  an  exposure  of  the  organ.  Slight 
lesions  and  complete  rupture  of  the 
kidney  cannot  be  differentiated  by  clin- 
ical signs  of  symptoms.  F.  G.  Connell 
(Jour.  Amer.  Med.  Assoc,  March  25, 
1911). 

The  recent  statistics  of  traumatic 
lesions  of  the  kidney  which  showed  a 
mortality  of  14.6  per  cent,  in  143  cases 
with  a  conservative  operation  and  of 
16.7  per  cent,  in  131  nephrectomies, 
while  20.6  per  cent,  of  the  427  patients 
not  submitted  to  operative  treatment 
died,  are  suggestive  when  we  consider 
that  only  the  severest  cases  are  oper- 
ated. The  main  points  are  to  determine 
whether  the  vessels  and  the  kidney  pel- 
vis are  torn  and  whether  there  is  infec- 
tion. The  intensity  of  the  hematuria 
is  not  always  an  index  of  this.  Cystos- 
copy, supplemented  possibly  by  catheteri- 
zation of  the  ureters,  alone  elucidates 
these  conditions  by  showing  whether 
the  urine  is  being  regularly  expelled  in 
a  strong  jet  from  the  ureter  mouth. 
If  the  urine  is  blood-stained,  this  shows 
which  kidney  is  injured  and  that  the 
pelvis  and  ureter  are  not  torn,  and  that 
the  passage  from  the  pelvis  to  the 
bladder  is  open.  If  the  bloody  urine 
is  expelled  in  approximately  normal 
amounts  and  rhythm,  conservative  treat- 
ment is  indicated,  but,  if  no  blood  or 
urine  enters  the  bladder  from  the  in- 
jured kidney  and  none  can  be  obtained 
through  the  introduced  ureter  catheter 
or  there  is  merely  blood  or  a  few  clots, 
there  is  evidently  some  laceration  of 
the  pelvis,  permitting  escape  of  the 
urine  into  the  surrounding  tissues,  or 
the  kidney  has  been  destroyed  to  such 
an  extent  that  the  secretion  of  urine  is 
arrested.  In  either  case  operative  treat- 
ment is  imperative.  If  stagnating  urine 
is  found  in  the  pelvis,  this  excludes 
laceration.  Operative  measures  should 
not   be    delayed.      Stagnation    of    urine 


in  the  pelvis  may  cause  intense  pain, 
which  evacuation  of  the  urine  relieves. 
Voelcker  (Beitrage  z.  klin.  Chir.,  Bd. 
Ixxii,  Nu.  3,   1911). 

PROGNOSIS.— Death  almost  in- 
variably attended  rupture  of  the  in- 
testinal tract  prior  to  the  introduc- 
tion of  exploratory  abdominal  sec- 
tion, and  prompt  resort  to  active 
surgical  procedures,  when  necessary, 
is  indicated. 

As  to  the  liver,  as  late  as  1864 
wounds  of  this  organ  were  considered 
as  practically  hopeless  in  every  in- 
stance. While  a  very  small  propor- 
tion of  these  cases  recover  without 
surgical  interference,  as  is  shown  by 
the  scars  occasionally  found  in  the 
hepatic  parenchyma,  the  fact  remains 
that  an  exploratory  laparotomy,  per- 
mitting the  surgeon  quickly  to  arrest 
the  loss  of  blood  in  case  of  hemor- 
rhage and  to  rid  the  peritoneal  cavity 
of  accumulated  extraneous  fluids,  has 
greatly  reduced  the  mortality.  The 
prognosis  becomes  much  more  un- 
favorable when  peritonitis  has  set  in, 
but  a  fatal  issue  may  sometimes  be 
averted,  even  in  advanced  cases  of 
this  complication,  by  surgical  inter- 
vention. 

Mayer  in  1872  published  statistics  of 
135  cases  of  subcutaneous  traumatic 
rupture  of  the  liver  in  conjunction  with 
subcutaneous  abdominal  injuries.  He 
gave  a  mortality  of  86.7  per  cent. 
Edler's  compilation  of  189  cases  in  1887 
showed  a  mortality  of  85.7  per  cent,  for 
all  cases  and  78.2  per  ^ent.  for  uncom- 
plicated cases.  One-third  of  all  the 
cases  died  of  hemorrhage.  More  re- 
cent collections  of  cases  are  as  follows : 
Terrier  and  Auvray  5  deaths  in  11 
cases.  Frankel,  1901,  17  deaths  in  31 
cases.  Wilms  reported  all  cases  occur- 
ring in  the  Leipzig  Clinic  during  five 
years  with  3  recoveries  in  19  cases. 
Giordano's  collection  of  257  cases  shows 
a  mortality  of  40  per  cent.    He   con- 


ABDOMINAL   INJURIES    (LAPLACE). 


119 


eludes  that  results  have  improved  eon- 
siderahl}^  since  Edler's  time.  Riebel 
(Quarterly  Bull.  N.  W.  Univ.  Med. 
School,  Sept.,   1910). 

The  same  remarks  apply  to  rupture 
of  the  gall-bladder. 

Slight  contusions  of  spleen  heal 
readily,  but  rents  and  tears  of  any 
importance  are  frequently  followed 
by  fatal  hemorrhage.  Abscesses  oc- 
casionally complicate  convalescence. 
The  great  majority  of  cases  of 
rupture  of  the  kidney  that  recover 
are  those  in  which  the  initial  lesion 
had  been  comparatively  slight.  In 
the  graver  cases,  in  which  there  is 
copious  hemorrhage  into  the  peri- 
nephric tissues  or  into  the  peritoneal 
cavity,  of  which  the  growing  exsan- 
guinity  of  the  patient  is  an  indication, 
the  prognosis  depends  upon  the 
speed  with  which  adequate  surgical 
procedures  are  instituted.  Occasion- 
ally, however,  the  blood  is  held  in 
check  by  the  renal  capsule. 

Two  cases  in  which  a  contusion  re- 
duced the  secreting  power  of  the  kidney. 
In  the  first  case  the  kidney  was  injured 
by  a  kick  from  a  horse,  and  a  latent 
nephritis  developed  with  tendency  to 
formation  of  stones;  in  the  second  case 
the  blow  left  a  cicatrix,  palpable  two 
years  later,  which  interfered  with  the 
secretion  of  the  organ,  but  did  not  seem 
to  impair  the  general  health.  The  prog- 
nosis in  contusions  of  the  kidney  de- 
pends on  the  presence  or  absence  of 
infection.  The  other  kidney  does  not 
suffer  unless  the  contusion  is  compli- 
cated by  an  infectious  process.  Simonin 
(Presse  med..  Mar.  13,  1909). 

The  prognosis  depends  greatly, 
therefore,  upon  the  patient's  ability 
to  stand  operative  procedures  suitable 
to  establish  a  positive  diagnosis  and 
bring  the  lesion  that  may  at  any 
moment  destroy  life  within  the  imme- 
diate reach  of  art's  highest  powers. 
When  serious  injury  is  rendered  prob- 


able by  the  nature  of  the  accident, 
and  the  symptoms  present  also  indi- 
cate a  serious  lesion,  an  exploratory 
incision,  if  the  patient  is  not  past 
relief,  a  careful  examination  of  the 
organs  involved,  arrest  of  hemor- 
rhage, closure  of  the  disrupted  tis- 
sues, or  cleansing  of  the  abdominal 
cavity  may  save  him  even  when  his 
condition  appears  almost  hopeless. 

Again,  the  prognosis  is  influenced 
by  the  time  elapsing  between  the 
accident  and  the  institution  of  surgi- 
cal procedures.  The  sooner  they  are 
resorted  to,  all  things  considered,  the 
greater  the  chances  of  success. 

No  case  can  be  considered  as  hope- 
less unless  a  subnormal  temperature, 
cold  and  cyanosed  extremities,  and 
other  signs  indicate  that  the  end  is 
near. 

Even  when  performed  late  in  the 
history  of  the  case,  adequate  operat- 
ive measures  sometimes  prove  suc- 
cessful. 

The  mortality  in  injuries  of  the 
kidney  is,  under  the  best  surgical 
procedures,  about  30  per  cent.  Death 
in  these  cases,  if  not  immediate,  as 
the  result  of  shock,  or  hemorrhage,  or 
injury  to  other  important  organs,  is 
due  (1)  to  anuria,  (2)  to  infection, 
or  (3)  to  secondary  hemorrhage. 
Anuria  is  probably  due  to  a  reflex 
contraction  of  vessels  in  the  sound 
kidney  owing  to  stimulation  of  the 
splanchnics  and  the  vagus  endings 
(Masius).  Secondary  hemorrhage 
may  not  occur  for  a  week  or  ten  days 
after  injury  and  is  then  due  to  a  dis- 
integration of  blood-clots,  which  are 
acted  upon  by  the  urine.  Infection 
may  be  (a)  local,  with  deep  cellulitis 
and  subsequent  general  involvement; 
(b)  peritonitis,  or  (c)  an  ascending 
involvement  of  the  opposite  kidney 
due  to  the  breaking  down  of  blood- 
clots  in  the  bladder.  Crawford 
(Amer.   Jour,  of  Surg.,  Feb.,  1908). 


120 


ABDOMINAL   INJURIES    (LAPLACE). 


The  early  recognition  of  a  rupture 
of  the  bladder  greatly  influences  the 
prognosis.  About  60  per  cent,  of  the 
most  unpromising  lesion,  intraperi- 
toneal laceration,  are  saved  by  prompt 
surgical  measures.  The  remaining 
40  per  cent,  are  unsuccessful  mainly 
on  account  of  delay  in  resorting  to 
abdominal  section.  A  favorable  re- 
sult has,  nevertheless,  followed  lap- 
arotomy as  much  as  fifty-four  hours 
after  the  rupture. 

TREATMENT.  —  Shock.  —  Shock 
or  collapse,  though  unreliable  as  a 
sign  of  severe  injury  to  the  abdom- 
inal viscera,  is,  nevertheless,  an 
alarming  condition,  especially  if  the 
temperature  is  subnormal  and  the 
breath  is  shallow,  and  it  should  at 
once  receive  attention.  The  patient 
is  placed  in  bed  with  the  head  low, 
and  a  free  supply  of  pure  air  insured, 
supplemented  with  oxygen  if  prac- 
ticable. Hot-water  bottles  are  placed 
around  him  and  he  is  covered  with 
blankets  previously  warmed,  if  pos- 
sible, or  wrung  out  of  hot  water. 

Two  main  elements  have  to  be 
borne  in  mind  in  this  class  of  cases : 
(1)  that  the  state  of  shock  is  due  to 
a  direct  commotion  of  the  sympa- 
thetic system  with  probable  inhibition 
of  the  heart's  action,  and  (2)  the  pos- 
sibility of  an  internal  lesion  which 
may  involve  death  by  exsanguination 
or  the  outpour  into  the  peritoneal 
cavity  of  gastric  or  intestinal  fluids. 
While  the  first  condition  calls  for 
stimulants  adapted  to  sustain  the  flag- 
ging heart  and  restore  the  action  of 
the  vasomotor,  the  agents  employed 
should  not  be  administered  by  the 
mouth,  since,  in  case  of  rupture  of 
the  stomach,  the  duodenum,  or  jeju- 
num, a  portion,  at  least,  of  the  fluid 
may  be  added  to  those  that  may  have 


found  their  way  into  the  peritoneal 
cavity.  Rectal  and  subcutaneous  in- 
jections should  be  resorted  to. 

If  no  remedy  be  at  hand,  subcuta- 
neous injections  of  1  dram  of  whisky 
or  brandy  may  be  employed,  and  re- 
peated every  five  or  six  minutes  until 
reaction  occurs.  A  turpentine  stupe 
or  a  fresh  mustard  poultice  (not 
plaster)  over  the  xiphoid  cartilage, 
and  a  rectal  injection  composed  of  a 
tablespoonful  of  turpentine,  a  raw 
egg,  and  a  teacupful  of  warm  water, 
sometimes  act  with  surprising  rapid- 
ity. Hypodermic  injections  of  ether, 
or,  better  still,  tincture  of  digitalis 
with  %2o  grain  of  atropine,  repeated 
in  fifteen  minutes,  are  necessary  to 
sustain  cardiac  action.  After  the 
second  dose  the  digitalis  may  be  in- 
jected alone  several  times  more. 
These  measures  are  greatly  assisted 
by  galvanic  stimulation  of  the  phrenic 
nerve,  the  negative  pole,  moistened  in 
a  solution  of  chloride  of  ammonium, 
being  applied  to  the  neck  in  the  de- 
pression immediately  in  front  of  the 
sternomastoid  muscle,  and  the  posi- 
tive over  the  epigastrium. 

These  means  are  sometimes  ineffi- 
cient and  hypodermoclysis  should  be 
performed.  If  a  fatal  issue  seems 
inevitable,  saline  transfusion  is  indi- 
cated. 

In  abdominal  injuries  due  to  blunt 
force  the  symptoms  are  referable  to  the 
abdominal  wall  and  cavity,  or  both. 
Pain  may  be  severe  or  slight.  As  an 
early  symptom  vomiting  is  constant, 
distention  may  be  slow  or  rapid,  rigidity 
develops  later,  shock  may  or  may  not 
be  present.  The  temperature  and  pulse, 
particularly  the  latter,  are  considered  of 
great  importance.  Opium,  even  in 
small  doses,  renders  the  diagnosis  of 
such  injuries  difficult,  and  should  never 
be  administered  early.  After  an  ab- 
dominal injury,  if  there  is  tenderness, 


ABDOI^NAL    INJURIES    (LAPLACE). 


121 


acceleration  of  the  pulse  tending  to  in- 
crease ever  so  slightly,  together  with 
abdominal  distention  and  a  rise  in  tem- 
perature, the  diagnosis  of  a  grave  injury 
is  made  absolute.  In  most  cases  but  a 
few  hours  of  close  observation  are 
required  to  establish  the  diagnosis. 
In  such  cases  exploratory  laparotomy 
should  be  performed  at  once  unless  the 
condition  is  so  desperate  that  anesthesia 
means  certain  death.  Fowler  (N.  Y. 
Med.  Jour.,  Aug.  19,  1899). 

In  cases  of  abdominal  contusion  the 
surgeon  before  operating  should  wait 
for  some  symptom  or  symptoms  indica- 
tive of  intestinal  injury.  As  in  the 
presence  of  shock  a  diagnosis  of  intes- 
tinal injury  caniiot  be  made,  the  author 
would  wait  for  reaction  to  take  place. 
No  one  symptom  is  pathognomonic  of 
intestinal  injury,  but  the  two  most  re- 
liable are  gradually  increasing  rigidity 
and  an  anxious,  careworn,  and  painful 
expression  of  the  face.  The  latter, 
which  comes  on  after  reaction  has 
taken  place  and,  it  is  supposed,  is  con- 
comitant with  development  of  peri- 
tonitis, is  regarded  as  the  most  posi- 
tive of  all  the  syinptoms  of  severe 
intra-abdominal  injury.  In  the  next 
group  the  author  would  place  deep 
and  perhaps  radiating  abdominal 
pain,  respiration  becoming  more  and 
more  thoracic,  vomiting  after  re- 
action, abdominal  distention,  increas- 
ing pulse-rate,  and  secondary  fall  in 
temperature.  The  subject  of  a  severe 
abdominal  contusion  should,  it  is 
urged,  be  carefully  and  constantly 
watched.  While  advising  delay  in 
doubtful  cases,  the  author  does  not 
mean  that  the  surgeon  should  wait  for 
serious  symptoms  to  become  so  pro- 
nounced that  a  positive  diagnosis  is 
assured,  for  then  operative  intervention 
is,  for  the  most  part,  too  late.  There  is 
a  positive  midway  between  operating  on 
every  case  and  waiting  for  an  assured 
diagnosis,  where  the  surgeon  can  say 
that,  owing  to  the  gradual  appearance  of 
certain  symptoms,  there  is  fair  reason  to 
think  that  the  intestinal  tract  may  be 
injured,  and  that  an  immediate  opera- 
tion will  give  the  best  chance.  Le  Conte 
(Annals  of  Surg.,  April,  1903). 


Immediate  laparotomy  is  urged  when 
the  abdominal  walls  are  rigid  and  there 
is  local  tenderness  after  a  contusion, 
and  when  these  symptoms  display  a 
tendency  to  increase  rather  than  to  sub- 
side. There  is  more  shock  when  the 
injury  is  from  an  object  acting  on  a 
large  expanse  of  the  abdomen  rather 
than  from  the  kick  of  a  horse  or  the 
like.  Normal  temperature  and  full 
pulse  do  not  exclude  serious  internal 
injury,  and  there  was  no  vomiting  in 
one  of  the  most  severe  cases.  Cautious 
percussion  may  reveal  dullness  corre- 
sponding to  an  effusion  of  blood,  bile, 
stomach  or  intestine  content  or  urine, 
and  its  progress  can  be  thus  traced  in 
some  cases.  Schmidt  (Deut.  med. 
Woch.,  xxxii,  Nu.  44,  1906). 

Analysis  of  17  cases  of  subcutaneous 
injury  of  the  digestive  tract  in  which 
an  operation  was  resorted  to,  showing 
that  operative  treatment  is  imperative 
at  the  earliest  possible  moment  when 
there  is  a  probability  that  the  stomach 
or  intestines  have  been  injured  by  a 
contusion.  If  the  shock  is  too  pro- 
nouncecl  for  immediate  operation,  every 
effort  must  be  made  to  bring  the  pa- 
tient out  of  the  shock,  with  restor- 
atives and  saline  infusion.  In  case 
of  small  circumscribed  injuries,  it  may 
be  sufficient  to  suture  the  wound  in  the 
intestine  and  to  reinforce  it  with  serosa 
drawn  up  over  it,  but  in  case  of  exten- 
sive injury  it  is  better  to  resect  the 
injured  portion.  Even  if  the  patient  is 
not  seen  until  after  the  peritonitis  is 
established,  an  operation  is  always 
justified,  although  the  prospects  of 
saving  life  are  then  small.  Careful 
rinsing  out  of  the  entire  abdominal* 
cavity  with  large  amounts  of  sterile  salt 
solution  should  never  be  omitted,  as  this 
is  the  only  means  of  cleansing  the  peri- 
toneal cavity  of  infectious  material. 
Voswinckel  (Archiv  f.  klin.  Med.,  Ixxix, 
No.  2,  1906). 

Treatment  of  contusion  of  the  abdo- 
men, based  on  48  severe  personal  cases. 
In  31  cases  the  operation  was  performed 
early;  22  of  these  patients  recovered, 
and  9  died;  all  the  6  patients  with  a 
tardy  operation  recovered  also.  Modern 
surgery    can    command    incipient    peri- 


122 


ABDOMINAL   INJURIES'  (LAPLACE). 


tonitis,  but  in  the  later  stages  it  is 
difficult  to  handle.  The  vital  energies 
can  be  sustained  by  administering 
saline  solutions  in  extensive  hemor- 
rhage. If  the  vital  energies  have 
already  ebbed  too  low,  then  the  sur- 
geon is  pow^erless.  In  one  of  the 
writer's  cases  the  intraperitoneal 
part  of  the  full  bladder  had  ruptured 
and  a  loop  of  small  intestine  had 
fallen  into  the  organ.  He  sutured 
the  bladder  and  transplanted  the  attach- 
ment of  the  peritoneum  to  the  bladder, 
suturing  it  at  a  point  lower  down  than 
normal,  and  thus  making  the  seat  of  the 
wound  extraperitoneal.  There  is  no 
danger  of  peritonitis  from  rupture  of 
the  bladder  if  the  rupture  is  entirely 
extraperitoneal.  Hildebrand  (Berl.  klin. 
Woch.,  xliv,  Nu.  1,  1907). 

Immediate  aseptic  abdominal  section 
is  indicated  in  every  doubtful  case  of 
abdominal  injury.  Important  points  in 
the  surgical  treatment  of  abdominal  in- 
juries :  1.  Apply  active  measures  to 
overcome  or  lessen  shock,  unless  signs 
of  active  hemorrhage  make  quick  action 
imperative.  A  reasonable  time  (one- 
half  to  three  hours)  may  be  allowed  in 
cases  of  profound  shock,  to  promote  a 
helpful  reaction.  2.  Cleanse  the  skin 
as  thoroughly  and  as  widely  as  in  any 
other  abdominal  case,  notwithstanding 
the  presence  of  indication  for  rapid 
work.  3.  Precede  an  exploration  by  an 
intravenous  saline  infusion  or  a  trans- 
fusion of  blood  when  symptoms  of 
hemorrhage  are  marked.  As  Crile  has 
noted,  "We  may  in  this  way  transform 
a  hopeless  case  into  an  average  risk." 
4.  Make  the  search  for  intra-abdominal 
injuries  thorough  and  systematic.  5. 
Cleanse  the  peritoneum  thoroughly  of 
septic  material  and  blood,  or  fluid  of 
any  kind.  This  is  best  done  by  large 
gauze  sponges,  followed  by  copious  irri- 
gation, leaving  the  abdomen  partly  filled 
with  saline  solution.  6.  Secure  absolute 
hemostasis  and  water-tight  repair  of  all 
wounds  and  ruptures.  7.  Introduce 
drains  whenever  viscera  have  been 
penetrated  or  ruptured.  8.  Use  intra- 
venous infusions  of  normal  saline 
solution  freely  postoperatively  in 
cases     of     marked     shock     or     acute 


anemia.  9.  Adopt  the  Fowler  posi- 
tion and  the  live  coil  in  all  cases  as 
soon  as  reaction  from  shock  is  ob- 
tained. 10.  If  intestinal  paresis  su- 
pervenes, lavage  every  four  hours 
will  accomplish  more  than  enemata. 
Goodrich  (Amer.  Jour,  of  Surg.,  Jan., 
1911). 

Reaction. — As  soon  as  reaction  oc- 
curs in  these  cases  another  danger 
threatens  the  patient,  that  of  hemor- 
rhage, which  the  state  of  collapse  has 
so  far  prevented  to  a  degree,  unless 
an  extensive  injury  has  caused  over- 
whelming exsanguination.  In  this 
event,  however,  the  patient's  recovery 
from  the  preliminary  shock  would 
hardly  have  taken  place.  Hence  the 
necessity  of  closely  watching  the 
sufferer. 

Cases  of  prolonged  collapse  some- 
times turn  out  to  be  trivial,  while  a 
short  period  of  it  may  be  the  prelude 
to  the  most  grave  complications. 
The  former  cases  are,  unfortunately, 
rare,  and  profound  shock  of  any  dura- 
tion should  be  looked  upon  with  sus- 
picion. This  is  especially  the  case 
when  a  second  period  of  shock  is 
passed  through — the  "relapsing  col- 
lapse" of  Bryant — indicative  of  a 
secondary  hemorrhage  or  the  giving 
way  or  separation  of  some  damaged 
tissues. 

That  cases  clearly  showing  by 
their  history  and  the  active  symptoms 
a  grave  injury  should  be  submitted 
to  surgical  measures  as  early  as  pos- 
sible will  hardly  be  gainsaid  in  the 
light  of  our  present  knowledge.  An 
equally  positive  conclusion,  based  on 
every  means  of  diagnosis  available, 
will  alone  warrant  the  assertion  that 
no  serious  injury  is  present;  but,  if, 
on  the  other  hand,  doubt  exists, 
abdominal  section  will  alone  .insure 
the  patient  adequate  protection.     If 


ABDOMINAL   INJURIES    (LAPLACE). 


123 


nothing  be  found,  no  harm  will  have 
been  done  if  precepts  governing-  asep- 
tic surgery  have  been  closely  fol- 
lowed ;  if  a  rent  in  the  liver,  an 
intestinal  tear  or  rupture,  a  serious 
hemorrhage  be  discovered  and  ade- 
quately dealt  with,  the  patient  will 
have  received  the  benefit  of  all  our 
art's  resources. 

The  seat  of  rupture  being  located, 
the  nature  of  the  injury  will  deter- 
rhine  the  procedure  to  follow,  linear 
enterorrhaphy  being  indicated  in 
longitudinal  ruptures,  and  circular 
enterorrhaphy  in  complete  ruptures. 
These  procedures  are  now  generally 
preferred  to  an  artificial  anus.  It  is 
sometimes  impossible  to  adjust  ade- 
quately the  edges  of  the  wound, 
owing  to  the  condition  of  the  margin, 
and  an  omental  graft  must  be  used 
to  cover  the  contused  area  so  as  to 
avoid  a   secondary  perforation. 

Considerable  extravasation  of  feces, 
blood,  and  other  liquid  or  semiliquid 
material  may  have  occurred  into  the 
peritoneal  cavity.  All  chances  for 
further  contamination  of  the  intes- 
tinal tract  having  thus  been  removed 
by  closure  of  the  rupture,  the  peri- 
toneal cavity  should  be  carefully 
cleansed  by  flushing  with  warm,  steri- 
lized water,  a  soft  aseptic  sponge 
being  employed  to  mop  gently  all  the 
surfaces  that  may,  in  any  way,  have 
come  in  contact  with  the  infectious 
fluids.  The  cavity  is  then  closed  and 
free  drainage  insured. 

Satisfactory  results  are  obtained 
even  in  cases  in  which  very  great  in- 
jury and  ample  opportunity  for  infec- 
tion of  all  wounds  have  markedly 
compromised  the  issue. 

The  after-treatment  should  be 
based  upon  the  necessity  of  insuring 
rest  for  the  intestinal  tract  for  a  few 


days.  This  may  be  carried  out  by 
administering  opiates.  The  patient's 
strength  should  be  sustained  by 
means  of  nutrient,  but  small  and  fre- 
quently administered,  enemata. 

Under  all  circumstances,  an  abdom- 
inal injury  should  cause  the  patient 
to  be  watched  several  days.  After  an 
uncomplicated  injury  he  should  re- 
main in  bed  and  be  placed  on  a  milk 
diet  for  a  few  days.  Anodyne  appli- 
cations over  the  abdomen  and  a  little 
morphine,  internally,  if  there  is  pain, 
is  all  that  is  usually  required  in  these 
cases.  In  the  less  fortunate  the  pro- 
cedure to  be  adapted  varies  according 
to  the  organ  involved. 

Intestines. — The  probability  of  a 
rupture  having  been  recognized,  the 
abdomen  should  be  opened  by  an  in- 
cision through  the  linea  alba,  and  any 
hemorrhage  quickly  arrested. 

The  next  step  is  to  locate  the 
visceral  injury.  Of  importance  in  this 
connection  is  the  fact  that  in  the 
majority  of  cases  the  rupture  is  due 
to  compression  against  the  spinal 
column.  The  spot  over  the  abdo- 
men upon  which  the  blow  carried 
being  considered  as  the  one  end  of 
an  imaginary  line  and  the  center  of 
the  vertebral  column  as  the  other 
end,  the  probabilities  are  that  the 
rupture  will  be  found  near  the  linear 
axis. 

Again,  if  the  rupture  cannot  be 
readily  found,  hydrogen  may  be 
gently  insufflated  into  the  rectum,  as 
advised  by  Senn,  and  the  spot  from 
which  the  gas  escapes  will  indicate 
the  location  of  the  rupture, — approxi- 
mately, in  the  case  of  the  small  intes- 
tine, and  accurately  below  the  ileo- 
cecal valve. 

Disorders,  or  lesions  other  than 
those    sought    after,    are    misleading 


124 


ABDOMINAL   INJURIES    (LAPLACE). 


conditions    that   should   be    borne    in 
mind. 

Lesions  of  the  jejunum  are  some- 
times difficult  to  locate. 

Given  a  case  in  which  an  injury  to  the 
abdomen  occurred  which  is  liable  to 
produce  rupture  of  the  intestine,  and 
the  abdominal  wall  is  found  rigid  and 
the  patient  suffering  from  pain  in  that 
region,  one  should  not  hesitate  to 
operate,  even  in  the  absence  of  all  other 
symptoms.  Golden  (Annals  of  Surg., 
Nov.,   1906). 

Two  cases  of  rupture  of  the  intestine 
successfully  operated.  One  patient  was 
struck  in  the  epigastric  region.  Lapa- 
rotomy was  performed  four  hours  after 
the  accident  and  a  large  tear  v/as  found 
in  the  upper  part  of  the  jejunum,  in- 
volving nearly  one-half  of  the  circum- 
ference of  the  bowel,  but  being  placed 
obliquely  to  its  long  axis  just  beyond 
the  duodenojejunal  junction.  The  tear 
was  closed  with  interrupted  Halsted 
stitches  and  a  few  supporting  Lembert 
stitches.  The  second  patient  was  pinned 
against  some  railway  sleepers  by  the 
arm  of  a  crane.  In  this  case  the  lapa- 
rotomy was  done  six  hours  after  the 
accident.  The  jejunum  was  completely 
torn  through  transversely  in  its  whole 
circumference,  and  including  two  or 
three  inches  of  its  mesentery.  The 
bowel  was  united  with  Lembert  sutures. 
Both  patients  recovered  promptly.  Mole 
(Bristol  Medico-Chir.  Jour.,  March, 
1907). 

Diffused  rigidity  of  the  abdominal 
wall  in  a  case  of  contusion  of  this 
region,  even  in  the  absence  of  any  other 
serious  symptom,  is  a  decided  indication 
for  immediate  laparotomy,  while  the 
absence  of  contracture,  whatever  may 
be  the  extent  and  gravity  of  the  asso- 
ciated symptoms,  contraindicates  sur- 
gical intervention.  Of  10  cases  in  which, 
owing  to  the  presence  of  this  symptom, 
laparotomy  was  performed,  this  treat- 
ment proved  successful  in  9.  Of  17 
cases  of  severe  abdominal  contusion  in 
which  no  operative  treatment  was  ap- 
plied in  consequence  of  the  absence  of 
rigidity,   all   ended   in  recovery.     Hart- 


mann  (Bull,  et  Mem.  de  la  Soc.  de  Chir., 
Mar.  12,  1901). 

Reviews  of  19  operations  performed 
on  patients  who  suffered  from  rupture 
of  the  intestine,  resulting  from  blows 
upon  the  abdomen.  Not  infrequently 
such  injury  will  end  fatally  unless 
immediate  operation  is  done.  The  ab- 
dominal viscera,  although  they  have  no 
bony  wall  to  protect  them  in  front,  are 
protected  from  injury  by  their  position, 
and  by  the  immediate  involuntary  con- 
traction of  the  abdominal  muscles  which 
takes  place  the  moment  a  coming  blow 
is  seen  or  expected.  In  injuries  sus- 
tained through  contests  of  physical 
strength,  blows  upon  the  abdomen  are 
comparatively  rare  on  account  of  the 
protected  position  in  which  the  abdomen 
is  held.  The  author  comes,  therefore, 
to  the  conclusion  that,  where  rupture  of 
the  intestine  takes  place,  the  intestine  is 
generally  caught  between  the  body 
which  causes  the  blow  upon  the  abdo- 
men and  one  of  the  bony  structures 
which  form  its  posterior  walls.  F.  B. 
Lund  (Boston  Med.  and  Surg.  Jour., 
Nov.  20,  1905). 

Stomach. — When  the  symptoms  of 
complete  tear  are  recognized,  the 
presence  of  the  organ's  contents  in 
the  abdominal  cavity  render  an  imme- 
diate laparotomy  imperative.  The 
incision  should  include  the  tissues 
between  the  xiphoid  cartilage  and  the 
umbilicus.  If  the  tear  cannot  be 
quickly  found,  repetition  of  the  infla- 
tion with  hydrogen-gas  will  help  to 
locate  it.  As  soon  as  located  any 
bleeding  vessel  should  be  ligated,  and 
the  stomach  evacuated  and  cleansed 
through  the  adventitious  opening  of 
any  substance  that  may  have  re- 
mained in  it.  If  the  wound  be  a 
lacerated  one,  it  may  be  necessary  t-o 
pare  its  edges.  This  being  done,  the 
tear  is  clpsed,  the  mucous  membrane 
being  united  with  a  continuous  or 
interrupted  suture,  cut  short,  and  the 
muscular    and    serous    coats    by    the 


Lines  of  Incision  for  Abdominal  Exploration  and  Operation    (Laplace). 

1,  median  line;  2,  for  liver  and  gall-bladder;  3,  for  pyloric  end  of  stomach  and 
duodenum;  4,  4',  for  upper  abdomen,  including  stomach  and  pancreas;  5,  for  spleen;  6, 
for  tail  of  pancreas  or  greater  curvature  of  the  stomach;  7,  umbilicus,  median  line;  8, 
8',  9,  9',  10,  10',  for  intestines  according  to  location  of  injury,  8  being  the  best  for 
appendix  as  it  severs  no  muscular  fibers:  11,  vermiform  appendix;  12,  McBurney's  line; 
13,  cecum  and  ileum;  14,  anterior  superior  spinous  process  of  the  ileum;  15,  16,  17,  18, 
defective  incisions  for  appendicitis:  they  cut  across  deep  muscular  fibers;  19,  19',  for 
inguinal  hernia;  20,  20',  21,  21',  for  bladder  according  to  location  of  injury. 


ABDOMINAL   INJURIES    (LAPLACE). 


125 


continttotts  Lembert  suture.  Closure 
of  the  laceration  having-  removed  all 
danger  of  further  extravasation  into 
the  peritoneal  cavity,  the  latter  must 
be  flushed  with  warm,  sterilized 
water  and  mopped  out  with  a  soft 
sponge.  The  cavity  is  then  closed 
and  a  drain  left  if  the  peritoneal  sur- 
faces have  been  exposed  to  contami- 
nation for  some  time. 

Liver. — Especially  when  the  history 
of  the  case  seems  to  indicate  the  pos- 
sibility of  a  lesion  of  this  organ  is 
careful  watching  imperatively  de- 
manded, owing  to  the  violent  hemor- 
rhages which  they  involve.  Either 
this  complication  or  peritonitis  having 
been  recognized,  the  abdomen  should 
be  opened  at  once  in  the  middle  line. 
The  abdominal  wound  should  be 
large  enough,  if  possible,  for  the 
surgeon  to  see  the  liver,  but  in  every 
case  he  ought  to  make  a  careful  ex- 
ploration with  his  finger,  especially 
directing-  his  attention  to  the  convex 
and  posterior  surfaces  of  the  organ. 

When  a  rupture  is  found,  the 
wound  may  either  be  cauterized, 
plugged,  or  sutured. 

Plugging  with  antiseptic  or  aseptic 
gauze  seems  to  give  the  best  results, 
one  end  of  the  gauze  being  left  out 
at  the  angle  of  the  abdominal  wound. 
The  plug  should  be  removed  not 
earlier  than  the  forty-eighth  hour, 
lest  there  should  be  a  recurrence  of 
the  hemorrhage,  and  not  later  than 
the  fourth  day,  lest  a  biliary  fistula 
should  be  formed.  When  the  bleed- 
ing is  very  severe,  sponges  mounted 
on  holders  appear  to  produce  more 
satisfactory  pressure  than  simple 
plugging,  which  is,  perhaps,  better 
reserved  for  slighter  injuries.  Hot- 
water  irrigation  may  be  of  advantage 
in  these  cases.     A  ligature  should  be 


applied  to  any  large  vessel  which  is 
seen  to  have  been  torn.  Sutures  are 
particularly  useful  when  the  lacera- 
tion extends  deeply  into  the  substance 
of  the  liver,  since  by  their  means  the 
edges  of  the  wound  may  be  brought 
lightly  together  and  the  bleeding  can 
be  controlled.  Drainage  of  the  pelvic 
pouch,  by  an  opening  just  above  the 
pubis,  serves  best  to  give  free  pas- 
sage to  subsequent  discharges.  The 
capsule  should  be  included  in  the 
stitches.  The  prognosis  is  very  un- 
favorable when  peritonitis  has  oc- 
curred, but  something  may  still  be 
done  to  prevent  the  fatal  issue  by 
opening  and  afterward  draining  the 
abdominal  cavity. 

Spleen. — After  a  simple  contusion 
the  spleen  soon  returns  to  its  normal 
condition  without  further  trouble, 
and  a  few  days  in  bed,  coupled  with 
strapping  of  the  side  to  limit  motion, 
usually  suffice.  When,  however, 
there  is  laceration  of  the  parenchyma 
the  convalescence  is  slow,  abscesses 
following-  in  quick  succession.  After 
a  time  these  cease  and  recovery  is  un- 
interrupted. Symptomatic  treatment, 
revulsion  over  the  organ,  and  tonics 
may  shorten  the  duration  of  such 
cases. 

When  the  symptoms  do  indicate 
that  exsanguination  of  the  patient  is 
taking  place,  death  will  most  prob- 
ably follow,  although  the  hemorrhage 
is  not  as  copious  as  it  can  be  in  tears 
of  the  liver^  the  splenic  capsule  being 
more  elastic  than  that  of  the  latter 
organ.  Removal  of  the  organ  should 
be  resorted  to.  The  abdominal  wall 
is  opened  by  means  of  an  incision 
through  the  left  semilunar  line  and 
the  peritoneum  is  freely  opened.  The 
hand  being  introduced  into  the  cavity, 
all    adhesions    are    torn    up    and    the 


126 


ABDOMINAL   INJURIES    (LAPLACE). 


organ  is  brought  to  view.  The 
vessels  entering  the  hikim  are  then 
clamped  and  the  organ  is  removed. 
The  stump  is  ligated  and,  after  spong- 
ing out  the  abdominal  cavity,  the 
wound  is  closed. 

A  study  of  a  personal  case  of  rupture 
of  the  spleen,  and  70  cases  recorded  in 
the  literature  since  1891,  showed  that 
immediate  operation  is  indicated  in  all 
cases  as  soon  as  the  diagnosis  is  made, 
even  though  there  may  not  be  much 
hope  of  saving  the  patient's  life.  In 
the  70  cases  referred  to,  42  patients 
were  operated  on  ;  of  these,  27  lived  and 
15  died,  a  mortality  of  36  per  cent.  All 
those  not  operated  on  died.  The  causes 
of  failure  after  operation  were  perito- 
nitis of  other  viscera,  especially  the 
left  kidney;  injuries  of  the  left  pleura, 
other  injuries,  such  as  fracture  of  the 
base  of  the  skull,  and  operation  per- 
formed too  late.  The  majority  of  pa- 
tients show  no  abnormal  effect  except 
a  transient  anemia  and  leucocytosis, 
which  swings  back  to  normal  in  about 
a  month,  and  an  enlargement  of  the 
lymph-glands,  most  often  the  left 
axillary  and  inguinal.  Simpson  (Lan- 
cet, Aug.  11,  1906). 

Case  showing  that  extirpation  of  the 
spleen  is  the  best  means  of  treating 
traumatic  rupture  of  the  organ.  No 
functional  hypertrophy  of  any  other 
organ  was  observed  in  this  case,  nor 
any  signs  of  disturbances  from  lack  of 
functioning  of  the  spleen.  Borelius 
(Zeit.  f.  klin.  Med.,  Ixiii,  Nu.  1-4,  1907). 

Of  the  103  cases  of  traumatic  rup- 
ture of  the  spleen,  reports  of  which 
have  been  published,  the  injury  has 
been  inflicted  by  the  kick  of  a  horse 
in  11  instances.  In  a  case  personally 
observed,  treated  by  splenectomy,  sys- 
tematic examination  of  the  blood 
showed  that  the  removal  of  the  spleen 
had  absolutely  no  ill  effects.  Horz 
(Beitrage  z.  klin.  Chir.,  1,  Nu.  1,  1907). 

Summary  of  cases  of  rupture  of  the 
spleen  reported  in  literature :  Unop- 
erated:  Of  220  cases,  17  patients  recov- 
ered— mortality,  92.3  per  cent.  Opera- 
tive results :    Splenectomy,  67  cases,  38 


patients  recovered,  29  died — mortality, 
56.7  per  cent. ;  splenorrhaphy,  2  cases, 
1  patient  recovered,  1  died — mortality, 
50  per  cent. ;  tamponade,  6  cases,  5  pa- 
tients recovered,  1  died  —  mortality, 
83.3  per  cent.  In  the  splenectomies,  13 
patients  had  complicating  injuries,  of 
which  9  died.  In  2  which  recovered, 
the  complications  were  unimportant. 
Ross   (Annals  of  Surg.,  July,  1908). 

Case  of  rupture  of  the  spleen  in  a 
boy  of  seven  years  who  had  been  run 
over  by  a  cart.  Operation  by  Mr. 
D'Arcy  Power.  Chloroform  was  ad- 
ministered and  a  vertical  incision  was 
made  ZY2  inches  long  through  the  left 
rectus  muscle  above  the  umbilicus,  Ij^ 
inches  from  the  middle  line.  The  peri- 
toneal cavity  was  opened  and  was 
found  to  contain  a  quantit}^  of  blood- 
clot  and  blood  which  was  washed  out 
with  saline  solution  at  a  temperature 
of  110°.  The  anterior  surface  of  the 
left  lobe  of  the  liver  was  found  to  be 
grazed  over  an  area  of  about  the  size 
of  a  crown  piece,  but  had  stopped 
bleeding.  The  spleen  was  drawn  out  of 
the  wound  and  was  found  to  be  badly 
lacerated,  the  lower  third  of  the  organ 
was  almost  separated  from  the  rest,  and 
there  were  extensive  lacerations  in  the 
region  of  the  hilum.  The  organ  was 
held  in  place  by  a  mere  strand  of  mes- 
entery which  ruptured  when  an  attempt 
was  made  to  ligature  it.  As  bleeding 
had  also  stopped  in  the  spleen,  some 
of  the  arteries  of  which  were  very 
definitely  thrombosed,  no  attempt  was 
made  to  recover  and  ligature  the  ped- 
icle. The  bleeding  through  the  peri- 
toneal opening  had  never  been  very  free 
during  the  operation,  but  a  drainage 
tube  was  left  in  the  wound  to  be  an 
index  of  possible  further  hemorrhage. 
The  child  came  through  the  operation 
very  well,  and  there  was  no  further  ex- 
tensive hemorrhage,  the  drainage  tube 
being  removed  on  the  sixth  day,  when 
the  pulse  had  quieted  down  to  100.  The 
patient  made  an  uneventful  recovery. 
T.  S.  Lukis  (Lancet,  June  19,  1909). 

Kidney. — The  majority  of  mild 
cases  of  perirenal  extravasations  of 
blood  and  urine  recover  as  the  result 


ABDOMINAL    INJURIES    (LAPLACE). 


127 


of  rest  and  expectant  treatment.  The 
patient  should  be  kept  in  l)ed  and  his 
diet  limited  to  litiuids,  the  best  of 
which  is  milk ;  this  beverage  requires, 
besides,  the  least  physiological  labor 
from  the  injured  organ.  The  nourish- 
ment of  the  patient  may  further  be 
sustained  by  rectal  injections  of  beef- 
tea,  and  these  should  entirely  be 
resorted  to  if  there  is  vomiting,  the 
latter  tending  greatly  to  encourage 
hemorrhage. 

Details  of  5  cases.  The  patients 
were  men  between  25  and  42,  a  woman 
of  30,  and  a  boy  of  12.  Unless  there 
are  signs  of  internal  hemorrhage,  abso- 
lute repose  and  ice  to  the  kidney  re- 
gion are  indicated.  The  patients  were 
all  dismissed  in  good  condition  after 
operative  intervention.  Yoshikawa 
(Beitrage  z.  klin.  Chir.,  Jan.,  1909). 

When  hemorrhage  occurs  in  the 
direction  of  the  bladder,  there  is 
likely  to  be  accumulation  of  blood- 
clots,  which,  if  small,  will  readily 
pass  out  with  the  urine.  Frequently, 
however,  the  clots  are  large  and  cause 
retention  of  urine  and  marked  tenes- 
mus. A  large  catheter  should  there- 
fore be  introduced  and  kept  in  situ 
when  the  hematuria  is  marked,  and 
the  bladder  occasionally  washed  out 
with  a  weak  boric  acid  solution. 
Median  urethrotomy  to  remove  clots 
and  relieve  retention  sometimes  be- 
comes necessary  in  these  cases. 
When  the  symptoms  do  not  improve 
under  these  measures,  an  incision 
should  be  made,  exposing  the  seat  of 
injury,  the  extravasation  removed, 
and  the  parts  restored,  by  appropriate 
measures,  to  their  normal  conforma- 
tion. 

According  to  Keen,  hematuria  is 
valuable  only  as  showing  the  fact  of 
rupture  of  the  kidney,  but  not  as  a 
symptom    by    which    to    decide    on 


operating.  It  is  not  the  visible  loss 
of  blood  by  the  bladder,  but  the 
easily  overlooked,  but  far  from 
dangerous,  bleeding  into  the  peri- 
nephric tissues,  or  into  the  peritoneal 
cavity,  that  should  receive  the  chief 
attention. 

Case  of  rupture  of  both  kidneys,  with 
intraperitoneal  hemorrhage,  in  a  girl 
aged  16  years,  who  fell  a  height  of  four 
feet  from  a  car,  landing  on  her  abdo- 
men across  a  rail.  She  felt  that  she 
"had  torn  something  loose  on  the  in- 
side," and,  although  she  had  some  pain, 
she  walked  home,  a  distance  of  about  a 
quarter  of  a  mile.  When  seen,  about 
an  hour  later,  she  had  a  temperature  of 
98°  and, a  pulse  of  127,  with  other  symp- 
toms indicating  severe  shock.  She 
vomited  a  greenish  material  several 
times.  The  abdomen  was  distended, 
the  right  rectus  rigid,  the  right  kidney 
region  tender,  with  dullness  on  the 
right  side,  especially  in  the  right  iliac 
fossa  (the  patient  was  lying  on  her 
right  side).  By  catheter  two  ounces 
of  very  bloody  urine  were  withdrawn. 
Intraperitoneal  rupture  of  the  right 
kidney  was  diagnosed.  Owing  to  ob- 
jections on  the  part  of  the  patient  and 
her  parents  the  operation  was  not 
begun  until  about  eighteen  hours  after 
the  accident.  She  stood  the  operation 
well  for  the  first  hour,  but  later  did 
poorly  because  of  the  great  loss  of 
blood.  A  large  quantity  of  blood  and 
urine  was  found  in  the  peritoneal  cav- 
ity, which  was  cleaned  out  and  flushed 
with  normal  salt  solution.  The  right 
kidney  was  found  low  in  the  abdomen, 
lying  directly  in  front  and  over  the 
third  and  fourth  lumbar  vertebrse.  It 
showed  three  transverse  rents  and  was 
tied  at  its  lower  pole  to  the  left  kid- 
ney by  a  dense  fibrous  band  a  half-inch 
in  diameter  (horseshoe  kidney?).  The 
left  kidney  was  literally  torn  into  frag- 
ments, entirely  without  a  capsule,  and 
separated  from  the  ureter.  The  ves- 
sels of  the  left  kidney  were  ligated  and 
all  the  pieces  removed.  A  portion  of 
the  right  kidney,  which  had  been 
mashed  into  a  pulp,  was  removed  also. 
The  remaining  portion  of  the  right  kid- 


128 


ABDOMINAL   INJURIES    (LAPLACE). 


ney    (not  more  than  two-fifths  of  the 
original    kidney    substance)     was    in    a 
very    bad    condition    and    showed    two 
rents.     It  was  packed  with  gauze.     The 
abdomen     was     filled     with     normal 
saline    solution    after    repeated   flush- 
ings,  then    closed   with   through-and- 
through  sutures  of  silkworm-gut,  and 
drained.       After-treatment     for     the 
shock    was    carried    out.      From    the 
time    the    reaction    set   in,    ten    hours 
after   the    operation,    the    patient    did 
well.    The  gauze  was  removed  on  the 
sixth  day.     A  urinary  sinus  followed, 
through    which    most    of    the    urine 
passed    for    the    next    five    days.      It 
closed    on    the    sixteenth    day.      The 
patient  sat  up  on  the  thirteenth  day 
and  left  the  hospital  on  the  twenty- 
third    day.     She    has    enjoyed    good 
health  ever  since  (now  more  than  six 
months)  and  passes  a  normal  amount 
of    urine.      A.     L.     Franklin     (Amer. 
Jour,  of  Surg.,  Oct.,  1906). 
.'     The    dangers     of    rupture    of    the 
kidney    are    mainly    hemorrhage    and 
sepsis.     When,  therefore,  the   symp- 
toms are  such  as  to  indicate  marked 
hemorrhage  or  sepsis,  and  especially 
if  a  tumor  form  quickly  in  the  lum- 
bar region,  an  exploratory  operation 
should   at   once   be   done.      If   severe 
laceration  be  present,  or  the  kidney's 
functions  be  practically  compromised, 
or    the    hemorrhage    be    such    as    to 
require  ligation  of  the  renal  vessels, 
lumbar  nephrectomy  should-  immedi- 
ately be  performed,  primary  nephrec- 
tomy being  safer  than  secondary  re- 
moval of  the  organ. 

Bladder. — When  a  patient  presents 
the  history  of  a  severe  abdominal 
contusion  or  crushing,  followed  by 
inability  to  micturate,  the  catheter 
should  at  once  be  used. 

The  presence  of  hematuria  will 
indicate  a  lesion  in  the  urinary  tract, 
kidney,  or  bladder.  If  the  urine  with- 
drawn is  observed  to  be  well  mixed 
with  blood  and,  instead  of  red,  it  ap- 


pear brown  and  smoky,  the  lesion  is 
probably  one  of  the  kidney.  If,  on 
the  contrary,  the  urine  be  bright  red, 
the  probability  is  that  the  bladder  has 
been  torn.  In  the  latter  condition 
the  diagnosis  may  also  be  assisted  by 
the  quantity  of  fluid  passed  at  a  given 
time.  If,  when  the  catheter  is  intro- 
duced and  after  a  history  marked 
with  shock,  no  urine  is  obtained,  the 
chances  are  that  not  only  the  bladder 
has  been  ruptured,  but  that  the 
laceration  is  extensive,  the  opening 
having  allowed  the  vesical  fluids  to 
escape  into  the  abdominal  cavity.  A 
free  flow,  on  the  contrary,  would  tend 
to  show  that  the  tear,  if  any  exist,  is 
small.  Of  course,  the  invagination  of 
the  intestines  into  the  vesical  open- 
ing, or  a  valve-shaped  laceration,  may 
cause  the  same  favorable  signs  to 
exist,  thus  misleading  the  diagnosti- 
cian. Very  small  lesions  may  be 
present,  sufficient  to  allow  the  urine 
to  escape,  drop  by  drop,  into  the  sur- 
rounding parts.  Detection  of  them 
is  very  difficult,  the  subsequent  com- 
plications alone  showing  the  presence 
of  extravasated  fluids. 

The  presence  of  any  tear,  except 
very  small  ones,  may  also  be  ascer- 
tained by  injecting  a  weak  boric  acid 
solution  into  the  organ,  through  the 
catheter.  If  a  rupture  be  present,  the 
bladder  will  not  fill  and  rise  above 
the  pubis.  Filtered  air  may  be  used 
for  the  same  purpose,  but  it  is  less 
satisfactory,  owing  to  the  danger  of 
secondary  collapse. 

The  urine  may  have  passed  into 
the  prevesical  connective  tissue  out- 
side the  peritoneum,  or  the  vesico- 
rectal or  vesicouterine  space,  owing 
to  a  rupture  in  these  locations.  This 
constitutes  the  extraperitoneal  lesion. 
Cellulitis  and  sloughing  rapidly  ensue 


ABDOMINAL   INJURIES    (LAPLACE). 


129 


without  subsequent  involvement  of 
any  organ  in  the  neighborhood  of  the 
lesion,  the  vagina,  the  rectum,  etc., 
the  patient  dying  from  septicemia. 

According  to  Sieur,  the  most  impor- 
tant signs  of  vesical  rupture  are:  a 
peculiar  pain  felt  at  the  time  of  the 
injury;  chilling  of  the  surface  of  the 
body,  which  persists  for  some  time; 
an  urgent  desire  to  micturate,  which 
the  patient  cannot  satisfy;  the  ab- 
sence of  any  vesical  swelling  above 
and  behind  the  pubes,  and  also  the 
absence  or  the  presence,  but  in  very 
small  quantity,  of  urine  in  the  blad- 
der. Catheterizing,  though  valuable, 
ought  not  to  be  practised  except  with 
great  caution. 

Pathology  of  rupture  of  the  bladder 
based    on   3    personal    cases   and    those 
found  in  literature.     In  many  instances 
the  rupture  was  not  diagnosed  until  too 
late     for    surgical     intervention.      The 
mortality  of  rupture  of  the  bladcjer  has 
dropped  from  43.5  per  cent,  in  1895  to 
30.5  per  cent,   in   1905,  when   operative 
treatment  can  be  instituted  in  time.     It 
is  especially  important  to  bear  in  mind 
the  possibility  of  rupture  of  the  blad- 
der  from   its   being  pushed   down   into 
the   small   pelvis   by   some   "physiologic 
trauma,"  the  attachment  to  the  omen- 
tum tearing  out  a  piece  of  the  attached 
bladder    wall    where    it   joins   the   rear 
wall,  when  cicatricial  changes  have  in- 
duced   unyielding    adhesions.      Golden- 
berg     (Beitrage    z.     klin.     Chir.,    Jan., 
1909). 
To    ascertain    whether    a    tear    be 
extraperitoneal    or    not,    a    measured 
quantity  of  a  weak  boric  acid  solution 
is  injected  through  the  catheter.     If 
the  full  amount  is  not  recovered,  the 
chances  are  that  the  rupture  is  extra- 
peritoneal. 

Rupture  into  the  peritoneal  cavity, 
the  intraperitoneal  form  of  lesion,  is 
less  urgent  as  far  as  symptoms  go. 
One,  and  even  two,  days  may  elapse 
before  active  symptoms  appear;  but, 
when  they  do,  rapid  progress  toward 


a  fatal  issue  from  general  peritonitis 
is  the  rule. 

Uncomplicated  contusion  of  the 
bladder  readily  yields  to  a  few 
days'  rest,  the  application  of  ice, 
and  general  symptomatic  treatment. 
When,  however,  there  is  cause  for 
suspecting  a  rupture  from  the  nature 
of  the  accident  or  the  violence  of  the 
blow,  the  catheter  should  at  once  be 
introduced.  The  presence  of  blood 
renders  operative  interference  im- 
perative. After  the  rectum  has  been 
distended  with  a  rectal  bag  an  inci- 
sion three  inches  long  is  made  in  the 
middle  line  of  the  hypogastrium, 
beginning  half  an  inch  below  the 
upper  edge  of  the  pubes,  as  in  supra- 
pubic lithotomy. 

The  peritoneum  is  then  carefully 
rolled  up,  along-  with  the  prevesical 
fat.  The  bladder  being  thus  exposed, 
search  for  the  rupture  is  the  next 
step.  The  rent  is  usually  found  along 
the  posterior  surface  vertically  down 
from  the  urachus ;  frequently  an 
extravasation  of  blood  and  urine 
indicates  the  spot.  Occasionally, 
however,  considerable  difficulty  is 
experienced,  and  opening  of  the  organ 
is  necessary  so  as  to  permit  the  in- 
troduction of  the  finger,  and  thus 
allow  of  exploration  of  its  inner 
surface. 

The  rupture  may  be  extraperi- 
toneal or  intraperitoneal.  If  an  intra- 
peritoneal laceration  is  found,  the 
incision  should  be  extended  upward, 
the  peritoneal  cavity  opened,  and  the 
cystic  wound  closed  with  fine  silk  by 
means  of  Lembert  sutures,  one-eighth 
of  an  inch  apart,  including  only  the 
peritoneal  and  muscular  coats.  The 
mucous  membrane  of  the  bladder 
should  be  respected.  Important,  in 
this   connection,   is   the   necessity   of 


1—9 


130 


ABDOMINAL   INJURIES    (LAPLACE). 


ascertaining-  that  the  sutures  will 
hold ;  this  may  be  done  by  distending 
the  bladder  with  a  lukewarm  milk  or 
an  alkaline  solution. 

The  abdominal  cavity  is  then  care- 
fully irrigated  and  closed,  leaving  a 
drain  if  there  is  any  possibility  that 
fluids  will  accumulate  in  any  of  the 
surrounding  tissues. 

Henry  Morris  holds  that  there  is 
great  danger  in  delaying  operation  in 
these  cases;  the  decomposition  of  the 
clots  and  the  cystitis  which  is  excited 
by  their  presence,  as  well  as  the  fre- 
quent catheterization  needed,  exposes 
the  patient  to  all  the  dangers  of  sup- 
puration of  the  wounded  kidney,  and 
also  to  the  risk  of  infection. 

WOUNDS  OF  THE  ABDOMEN. 
— Wounds  of  the  abdomen  may  be 
non-penetrating,  when  the  abdominal 
walls  alone  are  injured,  and  penetrat- 
ing, when  the  peritoneum  is  included 
in  the  lesion,  irrespective  of  the  in- 
strument (pistol,  knife,  etc.)  with 
which  the  lesion  is  produced. 

Non-penetrating  Wounds. — Non- 
penetrating wounds  are  usually  due 
to  pointed  cutting  or  blunt  instru- 
ments. 

The  lesions  caused  by  a  pointed  in- 
strument, involving  the  skin  and 
muscles  only,  are  usually  very  slight. 
,With  due  aseptic  precautions  careful 
exploration  of  the  wound  with  the 
finger  may  be  resorted  to  if  the 
visceral  examination  does  not  suffice. 
Probes  had  better  not  be  used,  lest 
the  wound  be  transformed  into  a 
penetrating  one. 

Lesions  caused  by  cutting  instru- 
ments (knives,  swords,  etc.)  vary  in 
importance  according  to  their  depth 
and  length.  When  the  muscles  are 
cut,  the  support  for  the  abdominal 
organs   is   compromised,   and   ventral 


hernia  may  follow,  unless  great  care 
be  taken  when  the  wound  is  closed. 

Lesions  caused  by  blunt  bodies 
(such  as  shot,  glancing  bullets,  and 
fragments  of  shells,  etc.)  are  usually 
attended  by  symptoms  of  contusions 
corresponding  in  intensity  with  the 
force  of  the  blow.  Severe  laceration 
of  the  abdominal  tissues  may  thus  be 
caused  and  death  occur  from  intes- 
tinal lesions. 

The  hemorrhage  attending  these 
various  kinds  of  wounds  is  usually 
slight.  There  is  considerable  ecchy- 
mosis,  but  this  soon  disappears.  Oc- 
casionally shots  or  bullets  become 
imbedded  in  the  abdominal  tissues. 

Treatment. — After  carefully  arrest- 
ing bleeding,  cleansing,  and  disin- 
fecting the  wound,  the  tissues  are 
united.  In  deep  incised  wounds  the 
prevention  of  ventral  hernia  should 
be  borne  in  mind,  and  the  cut  mus- 
cular tissues  broug^ht  accurately  to- 
gether by  means  of  catgut  sutures. 
This  being  done,  silk  sutures  are  also 
introduced  and  brought  out  to  the 
surface,  thus  including  the  muscles 
and  skin.  Capillary  drains  are  alone 
to  be  used,  if  drainage  is  at  all  neces- 
sary, larger  drains  affording  oppor- 
tunity for  the  formation  of  a  ventral 
hernia.  The  abdomen  should  be  sup- 
ported by  means  of  a  bandage  applied 
over  the  dressing  and  the  patient  kept 
in  bed  until  complete  repair  of  the 
wound  has  taken  place ;  from  two  to 
five  weeks,  as  a  rule.  The  bandage 
should  be  carried  long  after  recovery, 
and  the  patient  be  warned  of  the 
danger  he  might  incu-r  by  violent 
movement  or  strain. 

Penetrating  Wounds. — The  soft- 
ness of  the  tissues  of  the  abdominal 
parietes  causes  them  to  be  easil)^ 
penetrated,  and  the  organs  within  the 


ABDOMINAL   INJURIES    (LAPLACE). 


131 


eavlt}'  arc  all  vulnerable  for  the  same 
reason.  The  interstices  between 
them  occasionally  allow  the  harmless 
passage  of  a  weapon  or  bullet,  but 
such  cases  are  extremely  rare,  only 
nine  such  cases  ha^■ing•  been  recorded 
during"  the  Rebellion. 

The  missile  may  graze  the  perito- 
neum and  barely  miss  it  along  with 
the  deeper  organs.  Unfortunately 
wounds  causing  laceration  of  one  or 
more  of  the  abdominal  viscera  are  the 
most  frequent,  and  their  fatality  is 
proverbial  unless  a  timely  diagnosis 
allow  of  prompt  protective  measures. 

As  is  the  case  in  contusions,  the 
direction  from  which  the  missile  or 
stab  comes  is  of  great  importance. 
A  bullet  arriving  from  the  side  and 
striking  near  the  linea  alba  would 
probably  create  a  buttonhole  wound 
or  bury  itself  in  the  abdominal  walls. 
A  bullet  coming  from  the  front,  on 
the  contrary,  would  most  probably 
perforate  the  organs  in  its  axial  line 
of  flight.  If  the  bullet  has  passed 
through  the  body  an  imaginary  line 
between  the  entrance  and  exit  will 
probably  indicate  the  organs  injured, 
including,  of  course,  the  peritoneum. 
Here  again,  however,  the  spinal 
column  may  cause  deviation  when 
the  initial  velocity  of  the  bullet  is 
small,  and  a  deceptive  line  of  injury 
furnished.  To  positively  determine 
the  course  of  a  bullet  is  difficult  in 
many  cases. 

In  stab  wounds  the  opening  is  fre- 
quently of  a  sufficient  size  to  permit 
prolapse  of  the  omentum :  an  evident 
proof  that  the  abdominal  cavity  has 
been  penetrated.  This  rarely  occurs 
in  bullet  wounds  unless  a  large  pro- 
jectile, or  a  bullet  coming  from  either 
side  of  victim,  has  caused  com- 
paratively large  solution  of  continuity 


of  the  tissues.  Prolapse  of  the  omen- 
tum is  most  frequently  observed  in 
lesions  of  the  left  side.  Coils  of  the 
small  intestines  arc  also  frequently 
prolapsed  and,  in  rare  cases,  the 
stomach,  the  liver,  or  the  spleen  have 
appeared  between  the  lips  of  the 
wound. 

Symptoms. — As  is  the  case  after 
contusion,  penetrating  wounds  of  the 
abdomen  may  give  rise  to  no  symp- 
toms capable  of  affording  any  reliable 
clue  to  the  extent  of  the  internal  in- 
juries. Profound  shock  may  be  pres- 
ent and  no  serious  lesion  exist. 

Severely  injured  individuals  may, 
on  the  contrary,  present  no  acute 
symptoms  and,  perhaps,  walk  or  ride 
a  considerable  distance  before  show- 
ing noticeable  evidence  of  their  condi- 
tion. 

Profuse  hemorrhage  alone  gives 
rise  to  symptoms  denoting  a  grave 
lesion:  rapidly  progressive  exsangui- 
nation  or  acute  anemia;  nausea  or 
vomiting;  weak,  rapid,  and  some- 
times irregular  pulse;  dilated  pupils; 
cold  sweats ;  yawning,  ending  in  con- 
vulsions and  coma.  Shock  is  likely 
to  be  progressive  in  these  cases. 

The  only  symptoms  that  are 
present  in  practically  all  cases  are 
pallor  and  vomiting:  the  accompani- 
ments of  any  severe  blow  on  the 
abdomen,  and  therefore  of  no  value 
whatever  as  differential  signs.  The 
temperature  is  of  no  assistance  in 
these  cases. 

In  penetrating  wounds  of  the  abdo- 
men there  are  absolutely  no  known 
symptoms  which  indicate  injury  to  any 
of  the  viscera,  except  those  noted  in 
connection  with  the  urinary  tract, 
stomach,  and  occasionally  the  lower 
bowel.  Except  those  relating  to  gen- 
eral shock,  all  symptoms  following  such 
wounds  indicate  either  internal  hemor-' 


132 


ABDOMINAL   INJURIES    (LAPLACE). 


rhage  or  peritonitis.  To  wait  for  symp- 
toms of  perforation  of  the  intestines 
means  to  wait  until  peritonitis  has  de- 
veloped ;  therefore  every  bullet  or  stab 
wound  which  penetrates  the  abdominal 
cavity  should  be  operated  on  at  the 
earliest  possible  moment  in  order  to 
anticipate  the  advent  of  peritonitis.  No 
time  should  be  wasted  in  attempting 
to  demonstrate  the  presence  or  absence 
of  intestinal  perforation  by  such  means 
as  the  rectal  insufflation  or  gases  or 
vapors,  or  the  analysis  of  recollected  in- 
traperitoneally  injected  air  or  liquids. 

It  is  essential  to  systematically  ex- 
amine the  entire  gastrointestinal  canal 
in  all  cases,  regardless  of  the  point  of 
entrance  of  the  wounding  body.  When- 
ever the  alimentary  canal  has  been 
perforated,  suitable  drains  (the  author 
prefers  the  so-called  cigarette  drain) 
should  be  placed  either  through  the 
operative  incisions  or  counterincisions, 
as  may  appear  best  suited  to  the  indi- 
vidual case.  M.  L.  Harris  (Annals  of 
Surg.,  March,  1904). 

DIAGNOSIS.— On  general  prin- 
ciples dangerous  complications  are  to 
be  expected  when  marked  shock, 
nausea,  vomiting,  hiccough,  anxiety, 
intense  thirst  (indicating  a  probable 
involvement  of  the  peritoneum),  and 
insomnia  are  present.  Besides  these 
indications  there  are  others  peculiar 
to  each  organ  which  greatly  assist  in 
establishing  at  least  an  approximately 
certain  diagnosis. 

Intestines. — xAccording  to  Senn, 
bullets  striking  the  abdomen  antero- 
posteriorly  rarely  cause  more  than 
four  perforations,  while  oblique  or 
transverse  shots  are  likely  to  produce 
a  much  larger  number  of  lesions : 
from  fourteen  to  sixteen.  On  general 
principles,  however,  a  penetrating 
wound  may  always  be  considered  as 
having  caused  a  lesion  of  the  intes- 
tines. 

The  early  diagnosis  of  multiple  per- 
forations is  difficult,  _sometimes  impos- 


sible. Every  gunshot  wound  of  the 
abdomen  should  be  looked  upon  as 
penetrating  and  complicated  by  visceral 
injury,  especially  by  wounds  of  the  in- 
testine, unless  there  is  absolute  proof 
that  it  is  not  penetrating.  Whenever 
possible  a  median  exploratory  laparot- 
omy should  be  done,  without  regard  to 
the  seat  of  the  wound.  The  intestine 
should  be  explored  systematically  in  its 
whole  extent,  with  as  little  eviscera- 
tion as  possible.  After  repair  of  the 
lesion  a  careful  toilet  of  the  peritoneum 
should  be  provided  whenever  there  has 
been  a  considerable  escape  of  feces. 
Sourdat  (Rev.  de  chir.,  xxviii,  72>2), 
1908) . 

Whenever  there  is  acute  abdominal 
pain  the  possibility  of  perforation  of 
some  part  of  the  alimentary  canal 
should  be  considered,  and  the  patient 
should  not  be  dismissed  until  the  pos- 
sibility of  such  an  accident  can  be 
definitely  excluded.  If  the  symptoms 
point  rather  definitely  to  perforation, 
but  there  is  still  some  doubt  as  to  diag- 
nosis, an  exploratory  operation  is  safer 
than  delay.  Shock  is  no  contraindica- 
tion to  operation,  which  should  be  as 
expeditious  as  possible,  only  necessary 
work  being  done  and  artistic  ideals  be- 
ing left  for  less  urgent  conditions. 
The  writer  thinks  that  appendiceal  per- 
foration is  more  frequent  than  is  gen- 
erally supposed,  but,  as  in  gall-bladder 
perforations,  there  is  some  protection 
by  adhesion,  though  unfortunately  these 
are  not  always  life-saving.  B.  B.  Davis 
(Jour.  Amer.  Med.  Assoc,  May  14, 
1910). 

The  most  important  symptom  is 
the  escape  of  intestinal  gases  and 
more  or  less  fluid  substances  through 
the  wound.  The  mere  presence  of 
emphysema  around  the  wound  is  of 
no  value,  however,  since  air  is  gener- 
ally forced  into  the  wound  by  the. 
bullet. 

Case  of  a  boy  14  years  of  age  who 
was  shot  in  the  abdomen  at  close  range 
with  a  large  revolver.  He  presented 
an  irregularly  circular  wound  about 
one-half    inch    across    just    inside    the 


ABDOMINAL   INJURIES    (LAPLACE). 


133 


anterior  superior  spine  on  the  right 
side.  There  had  been  very  Httle  bleed- 
ing from  the  wound ;  there  was  no 
escape  of  gas  or  fluid  nor  any  viscus 
present.  The  abdomen  was  generally 
resistant,  both  flanks  were  dull,  but  the 
dullness  was  not  movable.  Liver  dull- 
ness appeared  normal.  The  pulse  was 
over  160,  respiration  rapid  and  shallow, 
pupils  dilated  and  expression  anxious. 
The  patient  did  not  complain  of  pain 
and  had  passed  clear  urine  since  receiv- 
ing the  injury.  The  bowels  had  not 
moved.  There  was  a  good  deal  of 
shock;  nevertheless  the  abdomen  was 
opened  immediately  in  the  midline, 
below  the  umbilicus,  by  an  incision 
about  three  inches  long.  Much  blood 
and  some  fecal  material  of  small  gut 
consistency  came  away.  The  small  in- 
testine was  delivered  and  almost  at  once 
a  wound  perforating  both  sides  of  the 
gut  was  found.  Near  it  was  a  lacera- 
tion on  the  antimesenteric  side  of  the 
gut  about  one  and  one-half  inches 
long.  There  was  also  much  bruising 
of  the  mesentery  between  these  two. 
The  three  wounds  were  closed  in 
the  usual  way.  Further  examination 
showed  seven  more  traumatic  perfora- 
tions of  gut  and  mesentery  within  a 
distance  of  six  feet.  All  this  and  the 
boy's  condition  made  the  case  seem  so 
hopeless  that  the  abdominal  opening 
was  closed  with  through-and-through 
sutures  after  a  large  drainage  wick  had 
been  placed  in  the  lower  angle  extend- 
ing freely  into  the  abdomen.  He  was 
freely  stimulated,  given  all  the  milk 
he  could  take  and  repeated  large 
enemas.  The  drainage  wick  was  re- 
moved on  the  second  day  and  not  re- 
inserted. On  the  third  day  a  small 
amount  of.  fecal  matter  was  passed  by 
rectum  and  daily  thereafter  the  quan- 
tity coming  away  naturally  increased, 
and  that  by  the  wound  decreased.  With 
the  first  stool  by  rectum  the  boy's  con- 
dition improved  and  it  did  so  steadily 
and  without  further  setback.  One 
month  after  the  accident  the  boy  was 
up  and  about,  and  it  was  found  that 
he  had  been  eating  rice,  bananas,  fish 
and  cakes  for  ten  days  previously. 
Fysche  (Montreal  Med.  Jour.,  May, 
1909). 


Free  hemorrhage  from  the  wound 
tends  to  indicate  an  intestinal  lesion ; 
if  the  stools  also  contain  blood  the 
diagnosis  may  be  considered  as 
certain. 

Probes  have  been  discarded  in 
penetrating  wounds,  owing  to  the 
irregular  course  followed  by  the  bul- 
let in  many  cases  and  the  danger  of 
creating  a  false  passage.  Digital  ex- 
ploration of  small  wounds  furnish  but 
little  information,  while  in  bullet 
wounds  there  is  danger  of  pushing 
into  the  peritoneal  cavity  what  for- 
eign substances  may  happen  to  be 
present. 

The  majority  of  surgeons  now  favor 
enlargement  by  an  incision  at  least 
two  inches  in  length,  intersecting  the 
bullet  or  incised  wound.  Layer  after 
layer  of  tissue  is  carefully  dissected 
on  each  side  of  the  track,  the  walls  of 
which,  in  gunshot  wounds,  are  usually 
darker  than  the  normal  tissues,  owing 
to  contact  with  the  lead  or  powder- 
products  of  combustion.  Using  the 
grooved  director  to  divide  the  tissues 
and  the  hemostatic  forceps  to  grasp 
any  bleeding  vessel,  the  peritoneum 
is  finally  reached,  when  the  certainty 
that  a  penetrating  wound  is  present 
or  not  may  be  established.  If  prac- 
tised with  strict  aseptic  precautions, 
this  procedure  does  not  expose  the 
patient. 

Stomach. — Hematemesis  is  a  fre- 
quent symptom  of  penetrating  wound 
of  this  organ  and  a  much  more 
valuable  one  than  in  contusion,  since, 
in  the  latter,  a  slight  laceration  of  the 
mucous  membrane  may  produce  it. 
The  blood  may  be  piu-e,  but  in  the 
majority  of  instances  it  is  mixed  with 
partially  digested  alimentary  semi- 
liquid  material.  If  the  wound  is  suffi- 
ciently large  to  allow  the  contents  to 


134 


ABDOMINAL   INJURIES    (LAPLACE). 


escape  through  it  the  nature  of  the 
injury  is,  of  course,  clear,  but  an 
important  complication  is  to  be  ap- 
prehended :  extravasation  into  the 
peritoneal  cavity  capable  of  causing 
peritonitis.  If  this  is  circumscribed, 
adhesions  are  formed  and  the  patient 
recovers.  Frequently,  however,  gen- 
eral peritonitis  follows,  ending  in 
death.  Hence  the  importance  of  an 
early  recognition  of  extravasation. 

Besides  hematemesis  and  the  pres- 
ence of  gastric  fluids,  there  are 
usually  present  in  such  injuries  the 
marked  symptoms  witnessed  in  cases 
of  contusion :  rapidly  progressive 
anemia,   pallor,   fluttering   pulse,    etc. 

Case  in  which  the  exit  hole  made  by 
the  bullet  in  the  stomach  could  not  be 
found,  though  it  had  unmistakably 
passed  entirely  through  it.  The  patient 
recovered  normally.  Research  on  ani- 
mals has  also  shown  that  the  hole  m.ade 
as  the  bullet  passes  out  of  the  stomach 
is  usually  a  small  slit,  discovered  with 
difficulty.  The  entering  hole  is  much 
larger  and  the  stomach  contents,  if 
they  escape  at  all,  do  so  through  this 
first  opening.  When  the  entering  hole 
is  not  more  than  7  or  8  mm.  in  diam- 
eter, it  is  wisest  to  abandon  the  search 
for  the  other  opening  if  it  does  not 
readily  present.  The  abdomen  can  be 
sutured  with  confidence,  as  the  mucosa 
plugs  the  second  opening.  Von  Frisch 
(Archiv  f.  klin.  Chir.,  Ixxiii,  Nu.  3, 
1904). 

Liver. — A  wound  of  the  liver  gives 
rise  to  all  the  symptoms  observed 
when  a  contusion  has  caused  lacera- 
tion of  the  organ :  Intermittent  pain, 
radiating  in  various  directions,  espe- 
cially toward  the  shoulder,  if  the 
convex  portion  of  the  organ  is  torn, 
and  in  the  direction  of  the  waist,  if 
the  concave  or  inferior  portion  of  the 
organ  is  the  seat  of  injury.  There  is 
marked     pallor,     superficial     itching, 


and,  later  on,  jaundice.  The  stools 
may  be  clay-colored,  thus  indicating 
the  absence  of  bile. 

The  hemorrhage  varies  in  these 
cases  according  to  the  cause  of  the 
lesion;  one  caused  by  a  bullet  is 
prone  to  be  accompanied  by  consider- 
able and  frequently  fatal  bleeding. 
Stab  wounds,  when  the  weapon  is  not 
large,  do  not  give  rise  to  considerable 
hemorrhage.  A  copious  flow  of  blood 
from  a  wound  in  the  hepatic  region 
indicates  that  the  liver  is  involved. 
The  flow  of  bile  through  the  wound 
is  a  A^aluable  sign,  but  it  is  seldom 
that  this  secretion  can  be  obtained 
alone,  blood  being  usually  mixed 
with  it. 

If  the  shock  is  progressive  it  means 
internal  hemorrhage.  When  a  patient 
is  first  seen  he  may  be  profoundly 
shocked  and  not  be  much  disturbed ; 
but  if  he  continues  to  become  more 
shocked,  it  means  hemorrhage.  Shock 
at  the  time  of  injury  does  not  mean 
hemorrhage,  but  later  on  it  does.  L. 
McLane  Tiffany  (Pacific  Record  of 
Med.  and  Surg.,  Feb.  15,  1896). 

In  very  severe  cases  the  prognosis  is 
exceedingly  grave,  no  matter  how  early 
intervention  may  have  been  practised. 
Hemorrhage  was  the  cause  of  death  in 
69  out  of  162  fatal  cases.  Abscess  and 
peritonitis  are  of  course  responsible  for 
many  deaths.  In  all  probability  there 
are  many  mild  cases  of  liver  laceration 
which  go  on  to  entire  recovery  without 
ever  having  been  diagnosed.  Of  25 
cases  of  hepatic  injury  occurring  in  the 
last  ten  years  in  the  New  York  hos- 
pitals, which  were  uncomplicated  by 
serious  lesions  of  other  abdominal  or- 
gans, 12  were  ruptures,  9  gunshot 
wounds,  4  stab  wounds.  Eleven  deaths 
resulted,  being  a  mortality  of  44  per 
cent.  B.  T.  Tilton  (Annals  of  Surgery, 
Jan.,  1905). 

The  gall-bladder  when  distended  is 
easily  ruptured  and  gives  rise  to  violent 
symptoms,  especially  if  already  infected, 
septic  peritonitis  being  inevitable..   E.  J. 


ABDOMINAL    INJURIES    (LAPLACE). 


135 


Senn    (Jour.   Anicr.   Med.   Assoc,   Mar. 
23,  1907). 

In  some  instances  extensive  lacera- 
tions of  various  organs  may  give  rise 
to  no  preliminary  morbid  phenomena. 
Thus,  W.  L.  Robinson  reported  fatal 
cases  of  marked  laceration  of  liver 
and  bowel  in  which  there  was  neither 
shock,  hemorrhage,  nor  high  pulse. 

Spleen. — In  cases  in  which  the 
spleen  is  wounded  the  diagnosis  can 
easily  be  established  by  the  location 
of  the  external  opening  and  the  direc- 
tion of  the  track.  As  is  the  case 
in  contusion,  there  is  marked  local 
pain  and  profuse  bleeding,  which,  if 
the  organ  is  greatl}^  lacerated,  may 
soon  prove  fatal.  This  is  apt  to 
occur  after  gunshot  wounds  at  close 
range,  the  organ  under  such  circum- 
stances becoming  pulpified.  Punc- 
ture wounds  are  less  likely  to  produce 
fatal  hemorrhage.  Pain  in  the  left 
shoulder  has  been  considered  a  diag- 
nostic of  value. 

Although  many  successful  operations 
have  been  done  of  late  for  wounds  of 
the  spleen,  little  attention  is  being  paid 
to  a  very  valuable  diagnostic  sign. 
Case  of  wound  of  the  spleen  in  a 
healthy  j^oung  man  in  which  the  physi- 
cian who  saw  the  case  soon  after  the 
accident  made  a  diagnosis  of  simple 
contusion  of  the  abdomen.  The  family 
physician  who  was  called  in  a  little  later 
found,  in  addition  to  pain  in  the  whole 
abdomen,  severe  pain  in  the  left  shoul- 
der. Because  of  the  increasing  shock, 
the  distention  of  the  abdomen,  the 
marked  right-sided  rigidity,  and  the 
severe  tenderness  in  the  region  of  the 
spleen,  a  wound  of  the  spleen  was 
diagnosticated.  The  writer  first  saw 
the  patient  in  the  evening,  and  agreed 
with  the  diagnosis.  He  was  partic- 
ularly impressed  with  the  fact  that  the 
patient's  chief  complaint  was  of  the 
pain  in  the  shoulder.  Immediate  lapa- 
rotomy established  a  wounded  spleen. 
This    organ,    which   was    exposed    with 


much  difficulty  because  adherent  to  the 
diaphragm,  showed  two  large  rents,  one 
near  the  hilum  and  the  other  on  the 
convex  surface.  Splenectomy  was  per- 
formed, and  three  weeks  later  the  pa- 
tient was  discharged  cured.  Pain  re- 
ferred to  the  right  shoulder  is  very 
characteristic  of  abscess  of  the  liver. 
This  applies  as  well  to  the  left  shoulder 
in  the  case  of  the  spleen.  It  is  ex- 
plained by  the  association  between  the 
phrenic  and  fourth  cervical  nerves. 
Levy  (Zentralbl.  f.  Chin,  Bd.  xxxvii,  S. 
1577,  1910). 

Kidneys.  — ■  Symptoms  frequently 
accompanying  wounds  of  the  abdom- 
inal organs — extreme  pallor,  weak 
pulse,  cold  extremities,  nausea,  and 
vomiting — are  apt  to  be  most  marked 
when,  besides  the  organ  itself,  the 
peritoneum  has  been  pierced. 

A  wound  of  the  kidney  gives  rise 
to  severe  pain  in  the  majority  of 
cases,  but  this  symptom  may  be 
absent.  As. in  cases  of  laceration,  the 
pain  radiates  in  various  directions,, 
especially  in  the  direction  of  the  ex- 
ternal genital  organs.  The  testicle  of 
the  corresponding  side,  besides  being 
the  seat  of  considerable  suffering,  is 
frequently  raised  by  spasmodic  con- 
tractions of  the  scrotum. 

At  first  a  small  quantity  of  bloody 
urine  may  be  passed,  but  this  is  often 
followed  by  vesical  tenesmus  and 
complete  retention,  due  to  the  pres- 
ence of  clots  in  the  bladder. 

Much  information  is  sometimes  ob- 
tained by  a  close  examination  of  the 
wound  of  exit.  If  the  track  of  Xhe 
bullet  be  anteroposterior  and  the 
missile  have  entered  from  the  front 
and  penetrated  the  kidney,  the  exit 
wound  will  be  found  in  the  lumbar 
region.  It  is  frequently  found  in  this 
situation  to  contain  urine,  a  positive 
indication  that  the  organ  or  its  annex, 
the  ureter,  has  been  wounded. 


136 


ABDOMINAL   INJURIES    (LAPLACE). 


The  diagnosis  of  gunshot  wounds  in- 
volving the  kidney  may  sometimes  be 
made  from  the  objective  signs  of  injury 
of  the  kidney;  in  other  cases  the  symp- 
toms will  be  those  of  shock  and  intra- 
abdominal bleeding,  as  in  stab  and  in- 
cised wounds.  The  cardinal  signs  are 
hematuria  and  the  escape  of  urine  from 
the  external  wound.  Owing  to  the  nar- 
row wound  of  entrance,  this  latter  sign 
is  much  less  common  in  gunshot  in- 
juries. 

If    either    ureter    is    plugged    by    a 
clot,  severe  renal  colic  may  be  present. 
In    gunshot   wounds    involving   the   ab- 
dominal   viscera,    operated    in    foi"    the 
control  of  bleeding  or  for  the  repair  of 
wounds  of  the  hollow  viscera,  it  will  be 
rare  that  the  surgeon  can  diagnosticate 
injury  of  the  kidney  before  opening  the 
abdomen,    unless    hematuria    or    kidney 
colic    have    existed.      Johnson    (Annals 
of  Surg.,  Oct.,  1909). 
If  the  wound  of  entrance  be  in  the 
back,  its  location  over  the  site  of  the 
kidney  may  suggest  a  lesion   of  the 
latter ;  but  the  urine  test  will  only  be 
of  value  if  the  projectile  only  pene- 
trate the  kidney  without  perforating 
it. 

If  it  penetrate  the  organ,  the  ex- 
travasation will  take  place  into  the 
peritoneal  cavity.  The  same  will  be 
the  case  if  the  missile  enter  from  the 
front  without  going  through  the 
organ.  Bullets  buried  in  the  renal 
parenchyma  either  become  encysted 
or  cause  abscesses,  and  pass  out 
through  the  ureters  or  into  the  ad- 
joining parts. 

Bladder. — The  symptoms  vary  ac- 
cording to  the  location  of  the  wound. 
A  perforation  between  the  symphysis 
and  the  peritoneum  above  does  not 
give  rise  to  general  symptoms ; 
whereas  shock,  pallor,  weak  pulse, 
vomiting,  etc.,  may  be  much  marked 
when  the  peritoneum  is  involved  in 
the  injury.  In  all  cases,  however, 
severe  pain  is  experienced  at  the  site 


of  the  lesion  and  radiating  to  the 
thighs  and  testicles. 

The  passage  of  urine  soon  becomes 
very  difficult  and  spasmodic.  It  may 
be  voided,  drop  by  drop,  for  a  long 
while,  notwithstanding  the  efforts  of 
the  patient,  then  suddenly  gush  out 
for  a  few  moments  and  again  flow 
slowly.  This  symptom  may  be  due 
to  accumulation  of  clots  or  to  spasm 
of  the  urethra.  If  the  catheter  is 
passed,  hematuria  becomes  evident 
when  the  bladder  has  been  pene- 
trated :  a  characteristic  sign. 

As  in  the  case  of  rupture  due  to 
contusion,  infiltration  may  take  place 
through  the  wound  into  the  neighbor- 
ing tissues ;  any  obstacle  to  the  free 
passage  of  urine  greatly  encourages 
this.  Hence  the  necessity,  in  all 
bladder  lesions,  of  keeping  the  organ 
as  free  as  possible  by  the  frequent 
use  of  the  catheter. 

Two  important  clinical  features  pres- 
ent in  cases  of  traumatic  ruptures  of 
the  bladder  that  are  not  noted  by  the 
classical  authorities:  (1)  The  persist- 
ent uniform  capacity  of  the  bladder, 
and  (2)  the  manner  in  which  the  blad- 
der may  be  refilled  after  complete 
evacuation  by  the  catheter.  The  first 
is  explained  by  the  fact  that  the  rupture 
is  situated  in  the  upper  part  of  the  blad- 
der, the  lower  part  of  which  still  acts 
as  a  reservoir.  When  the  urine  reaches 
the  level  of  the  rupture  it  escapes  into 
the  abdominal  cavity.  Repeated  cathe- 
terization will,  therefore,  withdraw  each 
time  about  the  same  quantity  of  urine, 
but  it  does  not  influence  the  urine  in  the 
abdominal  cavity.  The  second  symptom 
is  due  to  a  change  in  position  from  the 
recumbent,  in  which  the  urine  is  evacu- 
ated by  the  catheter,  to  the  upright,  in 
which  the  bladder  is  immediately  re- 
filled by  the  urine  which  has  escaped 
through  the  rupture  into  the  lower  part 
of  the  abdominal  cavity,  and  which  now 
as  readily  returns  to  the  bladder,  as 
shown  by  cadaveric  experimentation. 


ABDOMINAL  INJURIES    (LAPLACE). 


137 


Two  etiological  factors  were  noted 
in  these  cases,  the  tolerance  of  the  blad- 
der, which  can  be  distended  to  the  point 
of  rnptnre,  and  the  degeneration  of  the 
muscle  which  causes  a  diminished  re- 
sistance to  distention.  Morel  (Annales 
des  mal.  des  organes  genito-urin.,  June 
1,  1906). 

PROGNOSIS.— The  statistics  so 
far  pul)lislied  differ  so  widely  that  it 
is  difficult  to  reach  a  definite  con- 
clusion. It  is  certain,  however,  that 
gunshot  wounds  are  more  frequently 
fatal  than  stab  wounds,  but  that  stab 
wounds,  in  which  the  peritoneum  is 
penetrated,  are  fully  as  fatal  as  gun- 
shot wounds. 

The  kind  of  weapon  inflicting  the 
injury  plays  an  important  role  in  this 
connection.  A  triple-edged  bayonet 
is  more  likely  to  produce  a  serious 
laceration  than  a  flat  blade.  Again, 
wounds  caused  by  small  weapons, 
such  as  a  Flobert  rifle,  for  instance, 
would  hardly  produce  lesions  to  be 
compared  to  the  old  Enfield  or  Minie 
rifles,  which  sometimes  caused  a  large 
portion  of  an  organ  to  protrude 
through  a  wound  of  exit  the  size  of 
an  apple. 

Portions  of  the  solid  viscera  are 
sometimes  cut  ofif  or  shot  off,  leaving 
a  gaping  tear,  which  greatly  com- 
promises the  issue.  Again,  as  is 
often  the  case  with  the  liver,  the 
bullet,  or  any  foreign  material 
dragged  in  by  the  latter,  may  lead  to 
complications  which  greatly  reduce 
the  chances  of  recovery. 

An  important  factor  is  the  time 
elapsing  between  the  receipt  of  the 
injury  and  that  at  which  competent 
treatment  is  applied  in  mild  cases. 
This  is  especially  true  as  regards  the 
early  utilization  of  surgical  measures 
when  these  become  necessary.  The 
sooner  these  are  instituted,  the  more 


favorable    the    prognosis,    especially 
during  the  first  ten  hours. 

The  relation  between  spontaneous 
cures  and  operative  interference  as 
worked  by  Eisendrath  in  1902  is 
about  as  follows  : — 

Spontaneous  Recoveries. 

PER   CENT. 

Spleen 15.8 

Liver    21.8 

Intestines     7. 

Kidney   (extraperitoneal)    70. 

Kidney  (intraperitoneal)   0. 

Bladder  (intraperitoneal)    2. 

Bladder    (extraperitoneal) 11. 

Operative  Recoveries. 

PExC  CENT. 

56.  (50  cases). 

59.5  {2,7  cases). 

48.  (42  cases  prior  to  1896). 

50.  (38  cases  since  1896). 
80. 

100.  (  6  cases). 

52.  (43  cases). . 

30.  (last  15.  years).— Mitchell. 

Hence  the  need  of  abandoning  our 
policy  of  expectancy  and  delay  and 
to  recognize  our  duty  as  soon  as  even 
a  probable  diagnosis  of  rupture  of 
one  of  the  abdominal  viscera  without 
external  signs  has  been  made.  Rather 
a  few  laparotomies  in  vain  than  allow 
the  former  mortality  rate  to  continue. 

Intestines. — The  prognosis  depends 
greatly  upon  the  nature  of  the  lesions. 
Stab  wounds  opening  the  intestine 
lengthwise,  if  small,  often  heal  of 
their  own  accord;  transverse  wounds 
are  more  serious,  while  complete  sec- 
tion of  the  bowel  is  a  very  dangerous 
complication.  Gunshot  wounds  show 
a  great  fatality.  Prior  to  the  intro- 
duction of  antiseptic  surgery  the 
mortality  exceeded  90  per  cent. ;  since 
then,  the  mortality  has  been  de- 
creased to  43  per  cent,  in  cases  oper- 
ated   during   the   first   twelve   hours. 


i3S 


ABDOMINAL   INJURIES    (LAPLACE). 


When  all  surgeons  will  handle  the 
intestines  with  gentleness,  operate 
quickly,  and  otherwise  reduce  the 
chances  of  shock,  it  is  probable  that 
the  prognosis  will  be  greatly  im- 
proved. Perforations  of  the  descend- 
ing colon  and  sigmoid  flexure  are 
seldom  fatal ;  those  of  the  transverse 
colon  give  a  worse  prognosis,  by  the 
formation  of  fistulse,  adhesions,  and 
abnormal  communications.  Again, 
diai^thetic  conditions  may  compromise 
recovery. 

Notwithstanding  great  injury  and 
other  conditions  greatly  reducing  the 
chances  of  recovery,  recoveries  are 
occasionally  obtained. 

Statistics  collected  by  various 
writers,  according  to  Conner,  showed 
the  mortality  to  range  from  65.6  per 
cent,  to  70.67  per  cent.  Shock  is  one 
of  the  chief  causes  of  these  results. 

Case  of  a  penetrating  wound  of  the 
abdomen  in  which  there  were  19  per- 
forations in  the  small  intestines,  besides 
a  number  of  wounds  in  the  mesentery. 
Operation  was  performed  on  the  day 
following  the  injury,  and  fifty-one  days 
afterward  he  was  perfectly  well.  Iden 
(Medical  Record,  Nov.   IS,  1905). 

Stomach. — Uncomplicated  wounds 
of  this  organ  frequently  yield  without 
trouble  when  the  bullet,  blade,  or 
other  instrument  causing  the  perfora- 
tion is  small,  especially  if  the  stomach 
was  empty  at  the  time  the  injury  was 
inflicted.  The  mucous  membrane 
bulges  out  and  forms  a  plug  which 
obturates  the  hole  until  reparative 
processes  have  sealed  the  aperture  on 
the  peritoneal  side.  Complicated 
cases,  in  which  the  lesions  are  exten- 
sive, soon  reach  a  fatal  issue  if  de- 
prived of  timely  surgical  intervention. 

Liver. — The  prognosis  of  wounds 
of  the  liver  depends  mainly  upon  the 
complications.      If   the    patient    does 


not  die  from  hemorrhage  soon  after 
the  receipt  of  the  injury,  he  is  still' 
exposed  to  the  results  of  extravasa- 
tion into  the  peritoneal  cavity,  the 
presence  in  the  liver  of  a  foreign 
body, — the  bullet  and  what  material 
it  may  have  forced  into  the  wounds, 
— etc.  Peritonitis,  hepatitis,  and  ab- 
scess are,  therefore,  dangers  to  be 
taken  into  consideration.  Hepatitis 
and  abscess  are  much  less  to  be 
feared,  however,  from  stab  wounds, 
no  foreign  body  being  left  behind, 
unless,  as  in  dueling,  the  sword-point 
strike  the  spinal  column,  causing  the 
blade  to  break.  In  such  an  event, 
however,  the  hemorrhage  would 
probably  prove  mortal  very  rapidly. 

As  to  mortality,  the  statistics  of 
Edler,  Mayer,  and  others  show  it  to 
average  about  50  per  cent.,  including 
the  cases  attended  by  complications. 

Spleen. — Slight  punctured  wounds 
of  the  spleen  are  not  mortal  unless 
complicated  with  laceration  of  a  large 
artery.  They  are  sometimes  followed 
by  abscesses  which  heal  after  a  pro- 
longed period  in  the  great  majority 
of  cases.  Severe  punctured  wounds 
are  dangerous  in  proportion,  but,  if 
the  primary  hemorrhage  is  not  such 
as  to  cause  an  early  fatal  issue,  the 
chances  of  recovery  are  about  those 
of  slight  wounds. 

Gunshot  wounds  are  much  more 
serious  as  a  result  of  rupture  of  the 
spleen  taking  place  under  the  con- 
cussion. When  the  bullet  is  large 
and  its  velocity  is  great,  fatal  hemor- 
rhage quickly  ensues.  Rupture  of 
the  spleen  may  also  occur  during 
convalescence. 

During  the  War  of  the  Rebellion 
the  proportion  of  deaths  was  93  per 
cent.  In  civil  life,  however,  the 
weapons    used    are,    as    a    rule,    less 


ABDOMINAL   INJURIES    (LAPLACE). 


139 


powerful,  and  it  is  probable  that  the 
mortality,  especiall}'  since  antiseptic 
surgery  has  been  generally  utilized,  is 
much  smaller.  The  predilection  of 
this  organ  for  abscess  greatly  darkens 
the  prospects  of  recovery. 

Kidneys. — Complications  are  also 
to  be  feared  in  lesions  of  this  organ, 
namely :  peritonitis,  nephritis,  and 
secondary  hemorrhage.  Again,  the 
position  of  the  kidney  makes  it  prob- 
able that  other  organs  are  also  injured 
in  the  majority  of  cases.  The  direc- 
tion from  which  the  bullet  or  stab 
came,  the  length  of  the  penetrating 
blade,  etc.,  are  important  factors 
when  the  nature  of  the  injury  is  to 
be  determined. 

Bladder. — Gunshot  wounds  of  the 
bladder  are  always  serious  as  far  as 
complications  are  concerned,  rectal, 
vaginal,  perineal,  and  scrotal  fistulse 
being  very  frequent. 

As  to  the  mortality  of  penetrating 
wounds  of  the  bladder,  it  is  not  so 
great  as  in  lesions  of  any  of  the  other 
abdominal  organs.  Stab  wounds  are 
more  frequently  mortal  than  uncom- 
plicated bullet  wounds,  the  propor- 
tions being  29  per  cent,  in  the  former 
and  17  per  cent,  in  the  latter.  When, 
however,  osseous  lesions  are  also 
present,  penetration  or  fracture  of 
the  pelvis,  etc.,  the  mortality  reaches 
29  per  cent. 

Injuries  of  the  bladder  are  most 
frequent  in  males,  owing  to  greater 
exposure,  and  perhaps  to  anatomic 
causes.  Distention  is  one  of  the  main 
factors:  an  empty  bladder  is  rarel}- 
injured,  except  with  fracture  of  the 
pelvis.  The  majority  of  "bladder  tears 
are  intraperitoneal,  and  rapid  pro- 
gressive peritonitis  results  unless 
prevented  by  radical  surgery.  Viru- 
lent sepsis  follows  the  extraperi- 
toneal rupture.  E.  J.  Senn  (Jour. 
Amer.  Med.  Assoc,  Mar.  23,  1907). 


TREATMENT.— The  preliminary 
measures  indicated  in  the  treatment 
of  complicated  contusions  of  the 
abdomen  are  also  applicable  in  that 
of  penetrating  wounds  of  that  cavity. 
Protrusion  of  portions  of  the  intes- 
tines, the  mesentery,  and  the  omen- 
tum through  the  external  wound  is 
an  early  complication  met  with  in 
many  cases  of  penetrating  wound.  If 
the  protruding  mass  be  intestinal  and 
in  good  condition  it  should  at  once  be 
returned  into  the  abdomen.  An  easy 
way  of  accomplishing  this  (recom- 
mended by  Levis)  is  to  raise  the 
middle  of  the  patient's  body  by  means 
of  a  pillow,  the  hands,  etc.,  while  he 
is  lying  on  his  back.  The  anterior 
portion  of  the  pelvis  is  thus  separated 
to  an  abnormal  degree  from  the 
anterior  portion  of  the  thorax,  and 
the  increased  room  in  the  abdominal 
cavity  thus  obtained  causes  the  intes- 
tines to  spread  out,  as  it  were,  and, 
their  weight  causing  traction  upon 
the  protruding  loop,  the  latter  quickly 
slips  in. 

At  times  the  accumulation  of  gas 
or  fecal  matter  checks  its  inward 
progress ;  the  gas  can  easily  be  let 
out  by  inserting  a  clean  hypodermic 
needle  into  the  projecting  bowel;  the 
fecal  matter  can  also  be  reduced  in 
quantity  b}^  drawing  out  an  addi- 
tional portion  of  the  gut — thus  in- 
creasing the  size  of  the  loop — and 
gently  pressing  small  portions  of  the 
contents  into  the  unprolapsed  bowel, 
thus  diminishing  the  tension  of  the 
protruded  mass.  It  is  sometimes 
necessar}'-  to  enlarge  the  abdominal 
wound.  If  the  projecting  mass  be 
greatly  inflamed  the  latter  procedure 
is  unavoidable.  If  it  be  gangrenous 
it  had  better  be  incised  and  the  forma- 
tion of  a  fecal  fistula  permitted. 


140 


ABDOMINAL  INJURIES    (LAPLACE). 


To  obtain  a  closure  that  will  prevent 
hernia  and  protect  the  abdominal  wound 
against  infection,  the  writer  recom- 
mends the  following  method :  The 
ordinary  "gridiron"  operation  is  done, 
and  the  peritoneum  is  then  caught  up 
and  incised  in  the  line  of  the  skin  in- 
cision; each  side  of  the  peritoneal 
wound  is  then  drawn  out  and  sutured 
to  the  skin  on  both  sides  with  a  run- 
ning suture  of  catgut  or  a  few  inter- 
rupted sutures.  Retractors  may  then 
be  put  in  and  the  adhesions  broken  up 
and  the  appendix  removed;  one  or  two 
small  drains  are  now  placed,  and  each 
end  of  the  incision  closed  around  them 
by  means  of  one  or  two  through-and- 
through  silkworm-gut  sutures.  To  in- 
sure better  approximation  of  the  deep 
layer  of  muscles  a  silkworm-gut  su- 
ture m.ay  be  placed  on  either  side  of 
the  skin  incision  before  the  peritoneum 
is  opened,  and  left  to  be  tied  when 
the  operation  is  completed.  Torrance 
(Therap.  Gaz.,  Jan.,  1909). 

An  omental  protrusion,  if  healthy, 
can  be  immediately  returned,  but  if 
greatly  inflamed  or  gangrenous  it 
should  be  transfixed  near  the  abdom- 
inal wall  and  tied  with  a  double  liga- 
ture ;  then  excised.  The  stump  is 
then  secured  in  the  deeper  portion  of 
the  wound  with  ligatures  and  adhe- 
sive strips. 

Punctured  wounds  of  the  abdomen 
are  frequently  recovered  from  spon- 
taneously, owing  to  the  absence  of 
serious  visceral  lesions.  The  same 
statement  may  be  made  as  regards 
bullet  wounds,  but  with  less  empha- 
sis. That  laparotomy  should  be  per- 
formed in  every  case  is  a  view  that 
widespread  clinical  testimony  does 
not  sustain ;  but  that  a  wound  of  suffi- 
cient importance  to  cause  anxiety  be 
enlarged  down  to  the  peritoneum  to 
allow  of  a  careful  examination  and 
adequate  procedures,  if  need  be,  and 
that  laparotomy  proper  should  be  re- 
served   for    lesions    which,    from    the 


nature  of  the  symptoms,  tend  toward 
a  fatal  issue,  are  in  keeping  with  the 
teachings  of  the  most  advanced,  but 
safe,  surgery. 

Active  operative  intervention,  when 
admitted  by  the  general  condition  of 
the  wounded,  and  the  surrounding  cir- 
cumstances, is  indicated  in  all  cases  of 
perforating  wounds  of  the  abdominal 
cavity,  with  the  exception  of  wounds 
inflicted  with  the  modern  small-caliber 
undeformed  rifle  bullet.  In  these  cases 
expectant  treatment  gives  the  best  re- 
sults. All  those  wounded  in  the  abdo- 
men need  full  rest,  at  least  for  one 
week  after  the  infliction  of  the  wound. 
Wreden  (Military  Surgeon,  March, 
1907). 

Case  of  extensive  gunshot  wound 
caused  by  the  accidental  discharge  of 
both  barrels  of  a  shotgun  in  contact 
with  the  body.  The  contents  of  the  two 
barrels  struck  the  abdomen  at  and 
above  the  left  superior  spine  of  the 
ilium,  and  came  out  at  and  above  the 
iliosacral  joint,  tearing  away  all  the 
soft  tissue  from  the  crest  of  the  ilium 
and  the  crest  itself,  above  a  line  drawn 
from  a  point  one  inch  back  of  the 
anterior  superior  process,  around  the 
outside  of  the  bone  to  the  upper  limit 
of  the  sacroiliac  joint.  The  joint  was 
not  entered,  but  two  transverse  proc- 
esses of  vertebrae  were  blown  off  and 
many  pieces  of  detached  bone  were 
scattered  throughout  the  soft  tissues. 
The  peritoneal  cavity  was  entered,  ex- 
posing the  sigmoid  flexure,  the  lower 
pole  of  the  left  kidney,  and  the  ante- 
rior end  of  the  floating  rib.  It  could 
not  at  first  be  determined  whether  the 
sigmoid  was  perforated  or  not,  but  in 
one  or  two  days  leakage  of  gas  showed 
that  it  had  been  injured.  The  lumbar 
muscle  was  practically  destroyed.  As 
there  were  no  signs  of  serious  hemor- 
rhage and  it  was  recognized  that  the 
wound  had  been  practically  sterilized 
by  the  burning  of  the  discharge,  the 
attending  practitioner  wisely  refrained 
from  overmuch  probing  or  interference, 
merely  removing  loose  and  dead  tissue, 
clothing,  etc.,  and  applying  a  sterile 
dressing.     In  about  two  weeks  the  pa- 


ABDOMINAL   INJURIES    (LAPLACE). 


141 


ticnt  was  taken  b\-  train  to  New  York, 
about  1000  miles.  There  it  was  found 
necessary  to  remove  the  anterior  part 
of  the  crest  of  the  ilium,  which  had  be- 
come denuded  of  periosteum,  and  other 
portions  of  embedded  bone  that  were 
found,  and  zinc  plaster  was  used  to 
narrow  the  wound.  Another  operation 
was  performed  four  months  later,  anas- 
tomosing the  under  surface  of  the 
transverse  colon,  between  the  meso- 
colon and  omentum  at  the  junction  of 
the  middle  and  left  third  of  the  meso- 
colon with  that  portion  of  the  sigmoid 
which  could  most  easil}^  be  brought  into 
apposition.  A  fourth  operation  was 
undertaken,  still  a  year  later,  to  close 
the  intestinal  opening  and  furnish  a 
parietal  peritoneum,  against  which  the 
intestine  could  rest,  thus  minimizing 
chances  of  adhesion  and  protecting 
against  ulcerative  processes  in  the  ex- 
posed intestinal  area;  to  find  an  ex- 
ternal covering  for  what  must  be  a 
large  hernia,  and  to  devise  a  means  for 
controlling  its  extension  and  future 
enlargement.  The  patient,  at  the  time 
of  report,  two  j'ears  after  operation, 
was  in  excellent  health,  able  to  perform 
all  the  duties  and  functions  of  life, 
walking  four  or  five  miles  a  day  for 
recreation.  Polk  (Abstract  in  Jour. 
Amer.  Med.  Assoc,  from  Med.  Rec, 
Apr.  18,  1908). 

In  all  penetrating  wounds  of  the 
abdomen  seen  within  twelve  hours  of 
the  injury,  operation  should  be  done 
promptly.  The  incision  should  be  large 
enough  to  insure  a  thorough  survey  of 
the  abdominal  viscera  without  unduly 
exposing  them.  Extensive  evisceration 
is  unnecessar}^  and  unjustifiable,  greatly 
increasing  the  mortality.  Unless  the 
peritoneum  is  extensively  soiled,  intes- 
tinal contents  should  be  wiped  away 
with  salt  gauze  sponges,  irrigation  do- 
ing more  harm  than  good.  If  the 
closure  of  the  perforation  or  destruc- 
tion of  blood-supply  threatens  seriously 
the  usefulness  of  a  portion  of  the 
bowel,  resection  should  be  done.  If  the 
peritoneal  cavity  is  generally  or  exten- 
sively soiled,  or  if  there  is  any  con- 
siderable oozing,  drainage  is  safer; 
otherwise,  the   incision   may  be   closed. 


Postoperative  treatment-  is  very  im- 
portant. If  there  is  no  lesion  in  the 
large  bowel  salt  solution  and  coffee, 
of  each,  150  c.c,  should  be  given 
per  rectum  every  four  hours.  Branch 
(Annals  of  Surg.,  Aug.,  1911). 

When  surg-ical  measures  become 
necessary,  including-  enlargement  of 
the  wound,  the  patient  should  be 
placed  under  an  anesthetic.  The 
rectum  should  be  emptied  b}^  copious 
injections  containing  a  tablespoonful 
of  glycerin  to  the  pint.  A  subcu- 
taneous injection  of  morphine  (%^ 
grain)  is  recommended  by  many  sur- 
geons. If,  however,  there  is  a  tend- 
ency to  shock  without  much  pain, 
this  agent  had  better  be  withheld. 
Rectal  injections  of  whisky  and  warm 
water,  2  ounces  of  the  former  and  4 
of  the  latter,  is  useful  to  sustain 
cardiac  action.  It  may  be  repeated  in 
an  hour  i£  evidences  of  impending 
shock  are  still  present. 

If,  after  a  careful  examination  of 
the  enlarged  wound,  it  is  found  that 
the  peritoneum  is  not  involved,  the 
exposed  tissues  are  carefully  cleansed 
and  the  wound  is  closed,  deep  sutures 
being  used  to  hold  the  tissues  in  ac- 
curate apposition.  As  already  stated, 
the  possibility  of  ventral  hernia 
should  be  borne  in  mind:  the  patient 
should  be  kept  in  bed  for  some  time 
and  a  bandage  be  worn  until  all  local 
weakness  has  disappeared. 

If,  after  a  stab  wound,  the  parietal 
peritoneum  alone  is  found  incised  or 
penetrated  and  there  is  no  evidence 
that  the  organs  behind  have  suftered 
injur}'-,  the  tissues  must  be  cleansed 
with  great  care  and  the  peritoneal 
flaps  broug-ht  together,  the  serous 
surfaces  being  kept  in  contact.  A 
continuous  catgut  suture  is  used  for 
the  peritoneum;  the  muscles  and  skin 


142 


ABDOMINAL   INJURIES    (LAPLACE). 


are  then  united  and  the  Avound  is 
closed.  The  measures  ah'eady  out- 
Hned  to  prevent  ventral  hernia  are 
also  indicated  for  the  deeper  wound. 

V\'hen  laparotomy  becomes  neces- 
sary the  incision  should  be  made  in  a 
spot  affording-  the  operator  the  great- 
est opportunity  for  a  wide  field  of 
action,  and  should  be  sufficiently 
long.  AMien  performed  for  the  arrest 
of  dangerous  hemorrhage,  a  long 
median  incision  will  enable  the  sur- 
geon to  reach  any  organ  with  ease : 
an  important  factor,  for  the  missile  or 
blade  inflicting  the  injury  may  have 
traversed  harmlessly  between  several 
coils  of  intestine  and  have  caused  a 
rent  in  the  organ  most  remote  from 
the  point  of  entrance.  Again,  the 
incision  should  be  free,  so  as  to  make 
it  possible  to  easily  reach  all  parts  of 
the  abdomen  to  allow  of  a  thorough 
removal  of  all  extravasations  which 
might  otherwise  ultimately  cause 
complications. 

As  the  late  Nicholas  Senn  taught, 
one  of  the  important  elements  of  suc- 
cess in  the  treatment  of  gunshot  and 
stab  wounds  of  the  stomach  is  time. 
Unnecessary  time  lost  in  finding  and 
suturing  the  visceral  wounds  is  a 
source  of  immediate  danger  to  life 
which  should  be  eliminated  as  far  as 
possible  by  means  which  enable  the 
surgeon  to  make  a  quick  and  correct 
diagnosis,  and  by  resorting  to  a 
method  of  suturing  which  closes  the 
wound  safely  and  securely  with  the 
least  possible  delay,  and  which  leaves 
it  in  a  condition  most  favorable  for 
speedy  definite  healing.  It  is  well 
known  that  small  penetrating  wounds 
of  the  stomach  often  heal  without 
operative  intervention.  By  contrac- 
tion and  relative  displacement  of  the 
different  muscular  lavers  of  the  thick 


wall  of  the  stomach  the  tubular 
Avound  is  contracted  and  obstructed 
sufficiently  to  prevent  leakage  until 
the  canal  on  the  peritoneal  side 
becomes  hermetically  sealed  by  firm 
plastic  adhesions  which  prevent  ex- 
travasation during  the  time  required 
for  the  repair  of  the  visceral  wound. 
If  in  larger  wounds  of  the  stomach 
the  same  degree  of  occlusion  can 
be  accomplished  by  the  simplest  me- 
chanical means,  then  such  a  pro- 
cedure should  take  the  place  of  the 
more  time-consuming  methods  of  su- 
turing now  in  general  use.  This  can 
be  accomplished  with  the  purse-string 
suture. 

In  gunshot  injuries  the  defect  in 
the  stomach-wall  is  circular  and  the 
wound-margins  contused;  hence  the 
deep  sutures  could  at  first  furnish  a 
barrier  to  the  escape  of  stomach-con- 
tents only  for  a  short  time,  as  their 
hold  in  the  necrosed  tissues  would 
be  imperfect  and  only  of  brief  dura- 
tion. In  short  round  wounds  the  cir- 
cular suture  is  the  one  which  will 
bring  and  hold  together  in  permanent 
uninterrupted  contact  the  serous  sur- 
faces in  the  most  efficient  manner.  In 
the  treatment  of  gunshot  wounds  of 
the  stomach  the  principal  object  of 
suturing  should  be  to  close  the  per- 
foration in  such  a  way  as  to  guard 
securely  against  extravasation,  and  at 
the  same  time  approximate  and  hold 
in  apposition  a  maximum  surface  by 
intact  healthy  peritoneum.  This  is 
accomplished  by  making  a  cone  of 
the  injured  part  of  the  stomach  with 
the  apex  corresponding  with  the 
wound  directed  toward  the  lumen  of 
the  organ.  The  purse-s-tring  suture 
applied  in  the  manner  that  Avill  be 
described  in  the  experimental  part  of 
this    paper    will    maintain    this    cone 


ABDOMINAL    INJURIES    (LAPLACE). 


143 


until  the  healing"  of  the  visceral 
wound  has  advanced  sufficiently  to 
render  further  mechanical  support 
superfluous.  The  cone  on  the  mucous 
side  of  the  stomach  acts  in  the  manner 
of  a  valve,  which  in  itself  is-  an  ef- 
fective barrier  against  the  escape  of 
stomacli-contents,  while  the  circular 
suture  constitutes  almost  an  absolute 
safeguard  ag-ainst  leakage,  and  brings 
in  contact  the  serous  surfaces  in  the 
interior  of  the  cone.  For  wounds  of 
the  posterior  wall  of  the  stomach  the 
author  recommends  a  purse-string 
suture  of  heavy  durable  catgut  to  be 
applied  through  the  anterior  wound. 
The  anterior  wound  is  closed  with  a 
purse-string  suture  of  silk  of  medium 
size  applied  to  the  base  of  the  cone  on 
the  serous  side.  It  is  desirable  that 
the  circular  suture  should  cause  no 
necrosis  of  the  included  tissues.  By 
using  an  absorbable  suture  in  closing 
the  posterior  wound  in  the  interior  of 
the  stomach  this  object  is  gained,  as 
only  a  small  part  of  the  thickness  of 
the  stomach-wall  is  subjected  to  pres- 
sure, and  the  tension  caused  by  the 
ligature  is  gradually  lessened  by  sof- 
tening of  its  material,  and  is  entirely 
removed  by  the  absorption  and  diges- 
tion of  the  ligature  in  less  than  three 
weeks. 

The  wound  of  the  posterior  wall  of 
the  stomach  is  found  and  made  ac- 
cessible by  inserting  through  the  an- 
terior wound  a  grasping  forceps  with 
which  the  posterior  wall  is  seized  at 
a  point  where,  from  the  course  of  the 
bullet,  the  second  wound  is  supposed 
to  be  located.  Through  a  wound 
large  enough  to  admit  the  index  finger 
the  greater  part  of  the  posterior  wall 
of  the  stomach  can  be  made  acces- 
sible to  sight  and  touch,  and  the 
perforation  can  be  located  and  closed 


with  the  purse-string  suture  in  a  few 
moments.  In  doul^tful  cases  inflation 
of  the  stomach  should  invariably  be 
practised  for  the  detection  of  a  second 
and  possibly  a  third  perforation. 

The  experiments  demonstrated  the 
safety  of  the  circular  suture  in  the 
treatment  of  gunshot  and  other  pene- 
trating wounds  of  the  stomach.  All 
of  the  animals  operated  upon  in 
this  manner  recovered  and  the  repair 
of  the  injuries  as  shown  by  the 
specimens  are  ideal.  The  absence  of 
adhesions  over  the  posterior  wound 
and  their  constant  presence  over  the 
anterior  wound  indicate  that  the 
presence  of  the  silk  ligature  and  the 
needle  punctures  were  the  causes  of 
the  circumscribed  plastic  peritonitis 
which  produced  them.  In  none  of 
the  specimens  could  any  indications 
be  found  of  necrosis  of  any  of  the 
inverted  tissues,  and  included  in  part 
by  the  circular  suture. 

In  the  course  of  three  weeks  the 
continuity  of  the  mucosa  at  the  seat 
of  the  injury  was  completely  restored. 
The  result  of  these  experiences  has 
convinced  the  author  that  the  circular 
suture  compares  favorably  with  the 
methods  of  suturing  in  general  use, 
and  besides  has  the  great  advantages 
over  them  in  the  case  of  its  applica- 
tion and  the  saving  of  much  valuable 
time. 

Suturing  of  the  posterior  wound 
by  partial  eversion  of  the  stomach 
through  the  anterior  obviates  un- 
necessary handling  of  the  organ  and 
the  necessity  of  interfering  with  the 
vascular  supply  incident  to  exposure 
of  the  posterior  wound,  as  is  done  by 
the  methods  most  generally  practised. 
If  extravasation  into  the  retrogas- 
tric  space  has  taken  place,  flushing 
through   the  posterior  wound  and  a 


144 


ABDOMINAL   INJURIES    (LAPLACE). 


vertical  slit  in  the  gastrocolic  liga- 
ment and  gauze  drainage  through  the 
latter  are  invariably  indicated.  (N. 
Senn.) 

The  stomach  and  the  transverse 
colon  are  best  brought  to  view  by  an 
incision  through  the  rectus  muscle. 
In  the  case  of  the  stomach  hernia  of 
the  mucous  membrane  will  facilitate 
recognition  of  the  lesion.  The  as- 
cending colon  requires  lateral  incision 
on  the  right  side,  and  the  descending 
on  the  left.  These  also  should  be 
sufficiently  long  to  facilitate  the 
search  for  the  injury  or  injuries  that 
may  be  present  in  the  organ  itself  and 
beyond. 

The  incision  may  be  such  as  to 
intersect  the  wound  of  entrance.  This 
is  desirable  at  all  times,  the  aim 
being,  of  course,  to  always  avoid  un- 
necessary solutions  of  continuity. 
Such  an  incision  can  fortunately  be 
made  in  many  of  the  cases  in  which 
the  hemorrhage  is  not  formidable. 

Hemorrhage. — When  the  abdom- 
inal cavity  is  opened  and  the  hemor- 
rhage, which  is  usually  more  venous 
than  arterial,  is  marked,  the  blood 
rapidly  accumulates  in  the  most  de- 
pressed portion  of  the  cavity  from  an 
invisible  source.  To  mop  out  the 
blood  with  sponges  is  generally  rec- 
ommended ;  but  such  a  procedure  does 
not  cause  the  hemorrhage  to  cease, — 
the  first  desideratum.  In  these  formi- 
dable cases  an  assistant  should  at 
once  introduce  his  hand  through  the 
wound — hence  the  advisability  of  a 
long  incision — and  compress  the  ab- 
dominal aorta  below  the  diaphragm. 
This  procedure  immediately  checks 
the  flow. 

Six  personal  cases  of  injury  of  the 
liver  in  which  is  emphasized  the  value 
of  controlling  liver  hemorrhage  by  su- 


ture, making  the  peritoneal  toilet  by  dry 
sponging  instead  of  irrigation,  and  the 
avoidance  of  package  and  drainage.  J. 
E.  Cannaday  (Lancet-Clinic,  Nov.  10, 
1906). 

If  any  difficulty  is  experienced,  the 
digital  pressure  upon  the  aorta  may, 
for  an  instant,  be  decreased,  and  a 
sudden  gush  will  point  to  at  least  the 
direction  from  which  the  blood  comes. 
The  necessary  steps  are  then  taken  to 
arrest  the  flow,  and  the  abdominal 
aorta  is  released  as  soon  as  possible, 
— not  suddenly,  but  by  a  gradual  re- 
duction of  pressure. 

The  measures  to  be  employed  in 
arresting  hemorrhage  vary  according 
to  the  organ  involved.  Gunshot 
wounds  of  the  liver  are  frequently 
stellate,  and  rents,  radiating  from  the 
bullet-track  in  various  directions, 
greatly  increase  the  bleeding  surface, 
the  parenchyma  in  this  organ  taking 
part  to  a  great  degree  in  the  emission 
of  blood.  To  force  resilient  sponges 
into  these  tears  is  to  increase  their 
depth.  If  the  wound  be  not  very  ex- 
tensive, it  may  be  sutured  with  catgut 
or  cauterized  with  the  actual  cautery. 
If  the  wound  is  extensive  it  had  better 
be  packed  with  long  strips  of  iodo- 
form gauze,  one  end  of  which  is 
brought  out  of  the  external  wound. 

The  modern  tendency  in  wounds  of 
the  liver  is  toward  early  laparotomy. 
Open  wounds  should,  without  excep- 
tion, be  treated  by  enlargement  of  the 
wound,  exposure  of  the  liver,  and  de- 
termination of  the  site  and  extent  of 
the  injury.  Care  should  be  taken  to 
examine  the .  entire  liver,  as  a  second 
wound  may  remain  urmoticed  and  give 
rise  to  fatal  bleeding.  The  best  meth- 
ods of  stopping  hemorrhage  are  by  the 
use  of  sutures  or  gauze  packing.  If  the. 
former  are  used  they  should  include 
considerable  liver  tissue  at  the  edges  of 
the  wound  and,  if  possible,  go  down  to 


ABDOMINAL   INJURIES    (LAPLACE). 


145 


its  full  depth.  Gauze  packing  is  par- 
ticularly suitable  for  contused  wounds, 
gunshot  wounds  and  punctured  woimds, 
and  is,  furthermore,  a  useful  addition 
to  suture.  The  thermocautery  is  of 
very  little  value  in  arresting  hemor- 
rhage from  the  liver.  The  blood  and 
bile  can  easily  be  removed  by  flushing 
the  abdomen  with  hot  saline  solution 
or  by  dry  sponging.  Drainage  is  em- 
ployed in  subcutaneous  wounds  chiefly 
for  the  purpose  of  arresting  hemor- 
•  rhage.  Tilton  (Annals  of  Surg.,  Jan., 
1905). 

When  the  intestinal  injury  and  intra- 
peritoneal hemorrhage  occur  together 
and  the  blood  is  extravasated  more 
quickly  than  the  intestinal  contents  the 
hemorrhage  acts  mechanically,  and  per- 
haps also  by  its  protective  power,  to 
encapsulate  the  peritonitis.  The  hem- 
orrhage will  be  brought  to  a  standstill 
more  quickly  by  the  tension  of  the  ab- 
dominal walls,  the  flatulence,  and 
paralysis  of  the  intestine  when  a  mesen- 
teric vessel  at  its  juncture  with  the 
intestine  is  injured.  An  intraperitoneal 
hemorrhage  may  thus  act  to  reduce  the 
threatening  danger  of  an  injury  to  the 
intestine  imder  favorable  conditions. 
Gutzeit  (Miinch.  med.  Woch.,  June  29, 
1909). 

The  spleen  is  next  in  order  as  to 
profuseness  of  hemorrhage.  The 
same  procedures  may  be  adopted  as 
for  the  liver,  but  the  introduction  of 
iodoform  strips  is  to  be  preferred.  If 
these  means  fail,  splenectomy  is  the 
only  measure  left. 

Particulars  of  3  cases  of  injury  of 
the  spleen,  bullet  wounds  in  2  and 
laceration  in  the  other  case,  which  ter- 
minated fatally  from  internal  hemor- 
rhage. The  spleen  was  removed  in  the 
other  patients.  One  was  a  man  of  66, 
and  the  remarkably  slow  recovery  was 
a  noticeable  feature.  It  seemed  as  if 
the  lack  of  regeneration  of  the  blood 
from  the  absence  of  the  spleen  retarded 
convalescence.  An  accessory  spleen 
was  found  in  the  other  patient,  a 
young  man  of  27,  and  his  prompt  re- 
covery may  have  been  facilitated  by  the 


presence  of  this  compensating  organ. 
Graf  (Miinch.  med.  Woch.,  lii,  Nu.  44, 
1905). 

The  writer  has  collected  70  cases  of 
rupture  of  the  spleen  recorded  since 
1891,  which  are  reported  with  sufficient 
fullness  to  admit  of  some  comparison. 
From  the  standpoint  of  treatment  there 
are  four  groups  of  cases:  (1)  those  in 
which  the  patients  die  at  once  or 
within  a  few  minutes  of  the  accident — 
which  hardly  come  within  the  range  of 
surgery,  as  no  case  of  successful  op- 
eration has  been  done  within  the  first 
hour;  (2)  those  in  which  the  symp- 
toms are  delayed  from  twenty-four 
hours  to  fifteen  days;  (3)  those — the 
majority — in  which,  after  the  initial 
shock  of  accident  is  recovered  from, 
symptoms  of  hemorrhage  appear  within 
one  to  twenty-four  hours;  (4)  the 
few  cases  in  which  the  symptoms  of 
rupture  of  the  spleen  are  present  which 
gradually  recover  without  operation. 
All  of  these  patients  should  be  operated 
upon.  G.  S.  Simpson  (Lancet,  Aug. 
11,   1906).. 

Tears  in  the  spleen  cause  hemor- 
rhage. This  may  be  slight  and  cease 
spontaneously.  But  it  may  go  on  until 
the  patient  has  become  dangerously 
anemic.  At  times  operation  is  done  on 
such  cases,  and  it  is  found  that  the 
bleeding  from  a  tear  in  the  spleen  has 
stopped,  or  at  most  requires  a  small 
plugging  with  iodoform  gauze.  In 
other  cases  the  tear  may  be  so  large 
that  no  other  means  are  left  than  re- 
moval of  the  organ.  This  must  be 
done  without  hesitation.  O.  Hilde- 
brandt  (Berl.  klin.  Woch.,  Jan.  7,  1907). 

Sometimes  a  portion  of  the  organ 
projects  through  the  wound;  removal 
of  the  protruding  portion  should  be 
practised  after  passing  a  ligature 
around  the  mass. 

The  walls  of  the  stomach  and  intes- 
tines may  also  give  rise  to  marked 
hemorrhage  notwithstanding  their 
comparative  thinness.  The  number 
of  vessels  coursing  through  them, 
however,    is    very    great.      In    these 


1—10 


146 


ABDOMINAL   INJURIES    (LAPLACE). 


cases  it  is  best  to  hem  the  margins 
of  the  wounds  with  fine  silk.  The 
bladder  may  be  treated  in  the  same 
way. 

The  mesentery  sometimes  bleeds 
profusely  when  perforated.  The 
mesenteric  vessels  should  be  ligated 
en  masse  with  fine  silk. 

Hemorrhage  of  the  kidney  is  ar- 
rested in  the  majority  of  cases  by 
iodoform-gauze  package.  If  this 
should  prove  inefifectual  the  organ 
must  be  exposed  and  the  vessels  tied 
if  possible.  If  not,  nephrotomy  or 
nephrectomy  should  be  resorted  to. 
The  latter  operation  does  away  with 
the  chances  of  complication  attending 
the  former,  while  the  kidney  of  the 
other  side  assumes  the  function  of 
both. 

Injuries  to  the  kidneys  are  common. 
At  times  one  or  two  small  tears  may 
be  seen  on  the  surface,  or  the  tears  may 
be  deep ;  and  again,  the  whole  organ 
may  be  crushed  into  two  parts.  The 
kidney  is  usualh'-  crushed  against  the 
first  lumbar  vertebra.  The  first  class 
of  case  shows  a  short  lasting  hematuria, 
but  no  anemia,  while  if  the  tears  are 
deeper  the  hemorrhage  may  last  for 
some  time.  In  the  case  of  a  completely 
torn  organ  one  finds  very  extreme 
anemia,  great  pallor,  cold  clammy  skin, 
and  restlessness.  The  abdomen  is  ex- 
cessively tender,  the  pulse  is  thready, 
and  the  impression  is  obtained  that  the 
patient  is  dying  rapidly  from  loss  of 
blood.  If  the  abdomen  is  opened,  huge 
effusions  of  blood  are  found,  and  in 
the  midst  of  the  blood  the  kidney  lies 
buried.  One  only  has  a  short  time 
during  which  one  can  still  save  the  pa- 
tient. For  the  first  two  classes  one 
waits  for  matters  to  develop,  but  in  the 
third  class  one  must  operate  and  re- 
move the  kidney  at  once.  O.  Hilde- 
brandt  (Berl.  klin.  Woch.,  Jan.  7,  1907). 
Four  cases  of  rupture  of  the  kidney 
treated  conservatively,  rather  than  by 
nephrectomy.  The  abundant  literature 
of  the  subject  shows  that  the   advan- 


tage lies  with  conservative  treatment. 
Surgical  interference  should  aim  to 
control  hemorrhage  and  prevent  ex- 
travasation of  blood  and  urine  into  the 
tissues  and  abdominal  cavity,  also  to 
treat  other  organs  which  may  have 
been  injured  simultaneously,  and, 
finally,  to  place  the  injured  kidney 
under  conditions  which  shall  be  most 
favorable  for  repair,  including  the  pro- 
viding of  means  against  the  occurrence 
of  infection.  An  operation,  if  indi- 
cated, should  not  be  delayed.  The  in- 
jury is  so  slight  in  many  cases  that  an 
operation  is  not  required.  The  condi- 
tions must  be  carefully  weighed  to  de- 
cide between  an  abdominal  or  a  lumbar 
incision.  Neilson  (Amer.  Jour.  Med. 
Sci.,  Jan.,  1908). 

The  tampon  should  be  employed  in 
tho?*^  cases  in  which  there  are  no  im- 
mediate signs  of  injury  of  the  kidney 
or  in  which  these  signs  come  on  slowly. 
In  these  cases  we  may  consider  that 
the  lesions  are  benign  and  the  hemo- 
stasis  due  to  spontaneous  clotting. 
Bleeding  may,  however,  occur  later  in 
these  cases,  from  the  withdrawal  of 
the  tampon  or  the  separation  of  a 
slough.  Of  6  cases  of  nephrectomy  for 
gunshot  wounds  of  the  kidney,  3  re- 
covered and  3  died.  Anuria  is  due  in 
the  greater  number  of  cases  to  a  reflex 
inhibition,  produced  by  the  trauma  of 
the  injured  kidney  upon  its  fellow,  and 
signifies  only  an  important  lesion  of 
the  renal  parenchyma.  The  coexist- 
ence of  a  wound  of  entrance  in  the 
lumbar  region  is  an  indication  for  an 
exploratory  incision.  Clement  (Ann. 
d.  mal.  d.  org.  gen.-urin.,  p.  1281,  1909). 

Perforation. — The  fact  that  the  in- 
testines are,  at  times,  perforated  in 
twenty  spots  by  a  bullet  suggests  the 
considerable  degree  of  care  that 
should  be  given  to  this  part  of  the 
procedure,  which  is  carried  out  in  the 
following  way:  The  perforation 
nearest  the  rectum  having  been  de- 
tected, the  portion  of  intestine  per- 
forated is  gently  brought  into  full 
view.    An  assistant  causes  the  gas  in 


ABDOMINAL   INJURIES    (LAPLACE). 


147 


the  portion  of  gut  below  the  lacera- 
tion to  escape  through  the  latter  by 
slight  pressure.  This  being  done,  the 
next  step  is  to  ascertain  whether 
there  is  another  perforation  above.  A 
fresh,  aseptic  glass  tube  is  placed  at 
the  end  of  the  insufflating  tube  and 
introduced  into  the  wound  with  the 
tip  directed  away  from  the  rectum. 
The  assistant  now  being  directed  to 
compress  the  intestine  below  the  per- 
foration, a  small  amount  of  gas  blown 
above  the  latter  will  inflate  the  upper 
segment  if  there  is  no  opening,  or 
indicate  the  location  of  the  perfora- 
tion if  there  is  one.  As  soon  as  the 
latter  is  detected,  the  tube  is  with- 
drawn, the  neighboring  intestine  on 
each  side  of  the  first  perforation  is 
disinfected,  and  the  opening  is  closed. 
This  procedure  is  renewed  until  all 
perforations  have  been  found  and 
closed.  This  plan  renders  unneces- 
sary the  removal  of  the  intestines 
from  the  abdominal  cavity  during 
any  part  of  the  operation,  the  source 
of  complications  in  many  cases,  and 
of  death  by  aggravated  shock  in 
others,  and  is  now  recommended  by 
the   majority   of  American   surgeons. 

Case  of  a  man  aged  28  years,  who 
was  accidentally  shot  in  the  abdomen 
in  the  region  of  McBurney's  point,  with 
a  32-caliber  revolver.  About  four  hours 
later  the  abdomen  was  opened  in  the 
median  line  and  was  found  full  of 
blood.  Nineteen  perforations  of  the 
small  intestine  were  discovered,  as  well 
as  several  wounds  of  the  mesentery. 
At  one  place  there  were  five  perfora- 
tions in  four  inches  of  gut,  necessi- 
tating resection.  End-to-end  anasto- 
mosis was  done,  using  the  Cushing 
suture,  and  the  other  perforations  were 
closed  with  purse-string  sutures.  The 
intestines  were  cleaned  with  gauze,  wet 
with  hot  salt  solution,  and  the  wound 
closed  without  drainage.  The  opera- 
tion consumed  two  and  one-half  hours, 


and  at  its  close  the  pulse  was  imper- 
ceptible at  the  radial,  facial,  and  tem- 
poral arteries,  and  the  heart  beats  were 
from  170  to  180  a  minute.  In  spite  of 
the  grave  condition  of  shock,  the  pa- 
tient rallied  very  quickly,  and  the 
wound  healed  by  primary  intention,  the 
man  returning  to  his  work,  perfectly 
well,  fifty-one  days  after  the  operation. 
Iden   (Med.  Rec,  Nov.  18,  1905). 

There  is  great  ground  for  the  ob- 
jection to  Senn's  method,  made  by 
many  surgeons,  as  regards  its  use  for 
purposes  of  diagnosis  prior  to  lapar- 
otomy, but,  in  the  detection  of  per- 
forations after  the  abdomen  has  been 
opened,  it  is  of  value,  and  may  be 
used,  at  times,  to  great  advantage. 

The  manner  of  closing  the  wound 
is  that  indicated  for  lacerations  fol- 
lowing blows.  The  stomach  and  in- 
testinal perforations  being  treated  in 
the  same  way,  the  margins  of  the 
wound  are  turned  inward  and  the 
serous  surfaces  are  united  by  a  con- 
tinuous, fine-silk  Lembert  suture  or 
by  interrupted  sutures,  including  the 
serous  and  muscular  coats  and  the 
submucosa.  These  are  cut  short  and 
left  in,  being  eventually  discharged 
per  aniim. 

At  times  the  tissues  around  a  per- 
foration are  sufficiently  contused  to 
render  an  omental  graft  necessary. 

Enterectomy  is  sometimes  required, 
and  not  infrequently  exsections  of  the 
intestine  are  necessary.  In  that  case 
the  intervening  portion,  if  it  is  not 
too  long,  had  better  be  resected,  thus 
avoiding  a  double  operation  in  the 
continuity  of  the  gut. 

After  the  active  measures  described 
have  been  carried  out  the  extravasa- 
tion of  the  contents  of  the  stomach 
or  intestines  may  make  it  necessary 
to  flush  the  peritoneal  cavity.  Warm, 
sterilized  water  should  be  used,  but 


148 


ABDOMINAL   INJURIES    (LAPLACE). 


care  should  be  taken  not  to  handle 
the  intestines  roughly.  By  turning 
the  patient  on  his  side-  the  fluid  is 
poured  out.  The  abdominal  cavity  is 
then  dried  with  large  sponges  wrung 
out  of  warm,  sterilized  water.  Chill- 
ing of  the  viscera  should  be  carefully 
avoided,  and  the  parts  should  be 
exposed  to  the  air  as  short  a  time  as 
possible. 

Drainage  is  sometimes  necessary, 
especially  for  wounds  of  the  solid 
viscera,  such  as  the  liver,  spleen, 
kidneys,  etc.,  in  which  active  meas 
ures  were  not  resorted  to  early.  The 
weight  of  evidence,  however,  stands 
in  favor  of  dispensing  with  drainage 
whenever  it  is  possible. 

Whenever  the  muscular  wall  is  rigid, 
no  time  should  be  lost  before  operating, 
or  at  all  events  seeking  the  assistance 
of  the  surgeon.  The  rigidity  is  due  to 
beginning  peritonitis,  which  is  well 
marked  within  two  and  a  half  hours 
of  the  injury.  If  one  operates  in  severe 
cases  early  one  can  obtain  much  more 
favorable  results  than  one  used  to  get 
when  one  waited  for  the  signs  of  peri- 
tonitis to  develop. .  Out  of  12  cases  of 
intestinal  injury,  the  writer  saved  5  by 
operation.  O.  Hildebrandt  (Berl.  klin. 
Woch.,  Jan.  7,  1907). 

Previous  to  1890  few  cases  of  intes- 
tinal rupture  were  treated  surgically, 
and  the  result  was  usually  a  fatal  one. 
From  1894  to  1904  there  were  32  re- 
coveries reported  in  English,  Ameri- 
can, French,  and  German  literature. 
Though  the  accident  is  relatively  rare, 
it  is  not  infrequent  in  occupations  in 
which  traumatism  by  squeezing  is  of 
common  occurrence.  Lumbermen  and 
coal  miners  are  exposed  to  such  acci- 
dents. Rupture  usually  occurs  where 
the  motility  of  the  gut  is  restricted  by 
a  short  mesentery.  The  omentum  usu- 
ally escapes  serious  injury,  while  the 
mesentery  undergoes  injury  similar  to 
that  which  is  sustained  by  the  gut. 
Conditions  are  more  favorable  for  an 
operation  when  the  accident  occurs  sev- 


eral    hours     after     a     meal.       Golden 
(Annals  of   Surg.,  Nov.,  1906). 

If  the  intestine  is  perforated  and  not 
repaired  the  patient  will  die.  The  in- 
strument inflicting  the  operation  is  not 
a  matter  of  much  moment.  Prompt 
and  immediate  operation  is  imperative. 
It  is  undesirable  to  probe  or  unneces- 
sarily manipulate  the  wound  with  the 
object  of  cleansing  it.  Excluding 
wounds  of  the  abdominal  region  and 
those  which  give  rise  to  dangerous 
hemorrhage,  or  pressure  of  the  brain, 
and  finally  those  in  which  the  position 
of  the  bullet  is  clearly  made  out  and 
its  removal  is  not  fraught  with  danger, 
simple  aseptic  dressing  and  awaiting 
developments  is  unquestionably  the  best 
policy.  Of  course,  where  bones  are 
broken  the  ordinary  treatment  of  bone 
fractures  is  in  order.  Shiels  (Amer. 
Jour,  of  Surg.,  Aug.,  1908). 

To  summarize :  we  will  say  that 
immediate  exploration  of  the  abdom- 
inal cavity  is  indicated  as  soon  as  it 
is  suspected  to  have  been  penetrated 
or  in  any  way  injured  by  a  trauma- 
tism. The  injury  to  its  contents 
must  then  be  repaired  under  strict 
aseptic  precautions.  The  value  of 
salt-solution  flushing  is  emphasized 
by  the  results  of  practical  experience. 

Should  no  lesion  be  found,  the 
mere  exploration  should  result  in  no 
serious  damage. 

After-treatment. — Food  should  be 
withheld  for  thirty-six  hours,  but  a 
little  water  and  brandy,  in  teaspoon- 
ful  doses,  may  be  allowed,  especially 
if  there  is  any  degree  of  shock.  In 
that  case  it  is  advisable  also  to  use 
stimulants  by  the  rectum  or  sub- 
cutaneously.  Nutritive  enemata  of 
beef-tea  and  milk  are  necessary  to 
sustain  the  patient's  powers. 

Proctoclysis  of  normal  salt  solu- 
tion according  to  the  Murphy  gradual 
method  should  be  resorted  to.  The 
head  of  the  bed  should  be  raised  to 


ABDOMINAL  INJURIES    (LAPLACE). 


149 


apply  the  Fowler  principle  favoring 
the  gathering  of  secretions  in  the 
pelvis,  where  the  absorption  is  less 
rapid. 

When  the  patient  is  placed  in  the 
bed  [semisitting  with  pillows  under 
the  knees — the  Fowler  position],  quan- 
tities of  warm  salt  solution  are  passed 
slowly  into  the  rectum.  The  mucous 
membrane  of  the  large  intestine  ab- 
sorbs fluid  with  great  rapidity  when 
that  portion  of  the  gut  is  in  its  nor- 
mal condition  of  moderate  distention. 
Ovepdistention  leads  to  spasm,  which 
expels  the  fluid.  Hence  the  fluid  must 
be  given  at  low  pressure  and  adminis- 
tration should  be  continuous.  The  sim- 
plest sort  of  apparatus  consists  of  a 
fountain  syringe,  a  large  rubber  tube, 
and  a  rectal  tip  of  hard  rubber.  The 
nozzle  that  is  used  is  angled,  has  one 
opening  on  the  end  and  several  on  the 
side,  and  this  nozzle  is  passed  so  that 
the  angle  fits  to  the  sphincter.  The 
tube  is  strapped  to  the  thighs  by  ad- 
hesive plaster.  The  hose  that  comes 
from  the  nozzle  is  attached  to  a  reser- 
voir, the  base  of  which  is  hung  from 
4  to  6  inches  above  the  level  of  the 
patient's  buttocks,  and  the  fluid,  there- 
fore, enters  the  rectum  only  about  as 
fast  as  the  rectum  will  absorb  it.  The 
reservoir  is  kept  hot  by  bags  of  hot 
water.  The  fluid  is  allowed  to  enter 
continuously,  unless  it  should  run  out 
from  the  side  of  the  tube ;  if  this  hap- 
pens, the  flow  may  be  cut  off  for  a 
short  time  and  then  allowed  to  begin 
again.  Gas  from  the  bowel  passes 
into  the  openings  of  the  tube,  and  every 
now  and  then  bubbles  up  through  the 
reservoir.  By  this  continuous,  low- 
pressure  instillation  (protoclysis)  an 
enormous  quantity  of  fluid  is  absorbed 
by  the  rectum.  In  some  cases  a  num- 
ber of  quarts  are  taken  up  in  twenty- 
four  hours.  The  absorption  of  this 
fluid  greatly  increases  the  amount  of 
urine  eliminated  and  stimulates  the 
heart.  The  reservoir  must  not  be  high. 
Increase  of  pressure  will  cause  expul- 
sion of  fluid  and  defeat  the  possibility 
of  continuous  administration.  ■  The 
plan  so  often  followed  of  keeping  the 


reservoir  high  and  limiting  the  flow  by 
a  clip  on  the  tube  is  a  mistake.    Murphy 
says :  "It  should  never  have  a  headway 
of    more    than     15     inches    hydrostatic 
pressure,  and  it  gives  the  best  and  most 
uniform  results  at  4  to  7  inches"  (Jour. 
Amer.    Med.    Assoc,    April    17,    1909). 
A  straight  tube  is  sometimes  responsi- 
ble for  expulsion  of  the  fluid,  because 
it  touches  the   posterior   rectal  wall  of 
a   patient   in   Fowler's   position.     J.    C. 
Da  Costa     (Modern    Surgery,    p.    1007, 
1910). 
During-     this     procedure     no     food 
should  be   given   by  the   mouth.     If 
the  patient  is  weak,  rectal  alimenta- 
tion is  indicated.     In  the  less  severe 
cases   liquid   food   may   be   permitted 
by  the  evening  of  the  second  day,  and 
soft,  easily  digested  food  after  a  week, 
rectal    alimentation    being    continued 
until  then. 

The  sutures  can  be  removed  on 
the  ninth  day.  The  closure  of  the 
external  wound  must  be  complete 
before  the  patient  can  be  allowed  to 
leave  his  bed,  and  the  danger  of  a 
ventral  hernia  should  be  counter- 
acted by  means  of  an  abdominal 
supporter. 

Hypodermic  injections  of  strych- 
nine, Yqq  to  Yso  grain,  three  times  a 
day,  according  to  indications,  will 
prove  most  effectual  in  maintaining 
the  strength  of  the  patient  and  toning 
the  muscular  wall  of  the  intestine. 
Wounds  Due  to  Military  Firearms. 
[See  supra,  Penetrating  Wounds, 
for  details.] 

During  the  Franco-Prussian  War 
German  soldiers  were  frequently 
found  suffering  from  wounds  of  so 
frightful  a  nature  that  the  French 
were  accused  of  using  explosive 
bullets  contrary  to  the  International 
Convention  to  that  effect.  AVounded 
limbs  showed  lesions  of  so  destruc- 
tive a  character  that  the  hole  made 


150 


ABDOMINAL   INJURIES    (LAPLACE). 


was  a  magma  of  muscle,  tendon,  bone, 
blood,  etc.  Dead  subjects  were  found 
with  their  heads  completely  shat- 
tered, the  brains  being  scattered  on 
all  sides.  The  good  faith  of  the 
French  was  soon  demonstrated,  how- 
ever, experiments  having  shown  that 
their  rifle,  the  Chassepot,  was  capable, 
when  fired  at  close  quarters,  of  creat- 
ing unusual  lesions  on  account  of  tlie 
initial  velocity  and  the  greater  rota- 
tion of  the  bullet.  This  was  attrib- 
uted mainly  to  the  reduced  diameter 
of  the  bore,  11  millimeters,  and  to  the 
increased  quantity  of  powder  used. 

In  1886  France  adopted  8  milli- 
meters as  the  caliber  of  her  military 
arm,  and  the  other  nations  soon  fol- 
lowed her  example.  The  United 
States  Government  adopted  two 
calibers,  one  of  7.62  millimeters  for 
the  army,  and  one  of  6  millimeters  for 
the  navy.  Contrary  to  all  expecta- 
tions, the  effects  noted  in  recent  wars, 
the  war  between  Chili  and  Peru,  in 
which  a  7.6-millimeter  caliber  was 
used;  that  between  China  and  Japan, 
in  which  a  7.9-millimeter  was  used  on 
the  Japanese  side,  and  the  more 
recent  Chitral  expeditions  and  Abys- 
sinian campaigns,  in  which  7.9-milli- 
meter and  6.5-millimeter  arms,  re- 
spectively, were  employed,  were  less 
destructive  than  the  larger  calibers, 
while  the  wounds  caused  by  them 
healed  with  greater  rapidity  than 
those  following  lesions  due  to  the 
action  of  larger  balls.  During  the 
Chilian  AVar  there  were  instances 
where  men  completely  perforated 
through  the  chest  would  suffer  from 
slight  shock,  a  slight  hemoptysis,  and 
soon  be  out. 

This  radical  difference  between  the 
destructive  power  of  large  and  small 
calibers,  or,  rather,  between  the  de- 


structive effects  of  an  arm  such  as 
the  Chassepot  (11  millimeters)  and 
the  modern  rifle  (6  to  8  millimeters), 
IS  mainly  attributed  to  the  fact  that 
lead  was  formerly  employed  in  the 
manufacture  of  bullets ;  whereas,  at 
present,  in  order  to  avoid  destruction 
of  the  bullet  during  its  progress 
through  the  barrel,  resulting  from  the 
great  increase 'of  the  powder-charge, 
and  with  the  view  of  reducing  the 
weight  carried  by  the  soldier,  owing 
to  the  introduction  of  repeating  arms, 
the  bullet  itself  is  either  made  of 
some  hard  metal,  or  it  is  covered  with 
some  such  substance  as  nickel,  steel, 
German  silver,  etc. 

These  physical  features,  added  to 
the  smaller  diameter  of  the  projectile, 
the  much  greater  velocity  with  which 
it  travels,  its  more  or  less  pointed 
tip,  cause  it  to  penetrate  soft  tissues 
as  would  a  long,  thin  blade,  separat- 
ing rather  than  destroying  them. 
Therefore  perforations  in  a  muscle 
are  clean-cut;  at  times  their  walls  are 
even  collapsed;  as  a  rule,  the  channel 
is  about  the  size  of  the  bullet ;  large 
blood-vessels  are  severed  and  bleed 
until  the  heart  ceases  to  beat,  etc. 

jVIajor  Lynch,  of  the  U.  S.  Army, 
states  that  there  is  considerable  dif- 
ference between  the  Russian  and 
Japanese  rifles.  The  former  has  a 
caliber  of  7.6  millimeters;  its  cartridge 
weighs  24  grams.  The  bullet  weighs 
14  grams  and  has  a  jacket  of  cupro- 
nickel.  Its  initial  velocity  is  2015 
feet  per  second.  The  Japanese  rifle 
is  6.50  millimeters  in  caliber;  the 
cartridge  weighs  22  grams ;  the 
charge  is  2.10  grams  of  smokeless 
powder.  The  bullet,  which  weighs 
11/^  grams,  is  32  millimeters  long 
and  is  made  of  hard  lead,  with  a 
German    silver    jacket.      The    initial 


ABDOMINAL   INJURIES    (LAPLACE). 


151 


velocity  is  2356  feet  per  second.  The 
different  initial  velocity,  etc.,  of  the 
Japanese,  as  compared  with  the  Rus- 
sion  rifle  bullet,  according  to  Major 
Lynch,  was  not  found  of  great  impor- 
tance, so  far  as  the  effects  produced 
by  it  on  the  tissues  of  men  hit  were 
concerned,  though  it  is  possible  that 
more  Russian  bullets  lodged.  The 
difference  in  caliber  of  the  two  rifles 
was  responsible,  however,  for  very 
great  differences  in  the  wounds 
caused  by  them.  The  wounds  due  to 
the  Russian  bullets  were  always  of  a 
much  more  severe  character.  While 
from  the  surgical  standpoint  the  ex- 
tremely small  caliber  of  the  Japanese 
rifle  is  desirable,  it  is  a  great  question 
if  they  have  not  carried  their  desire 
for  long  range,  flat  trajectory,  and 
light  w^eight  of  cartridge  too  far,  and 
have  thus  sacrificed  the  stopping 
power  of  the  bullet  to  such  an  extent 
that  their  weapon  does  not  yield  the 
best  results  in  war.  Certainly,  a  man 
hit  with  the  Japanese  bullet  will  come 
on  when  it  has  passed  through  his 
body  anywhere,  except  at  a  vital 
point.  The  wound  of  entrance  of  the 
Russian  bullet  was  naturally  of  larger 
size  than  that  of  the  Japanese,  as  was 
also  the  wound  of  exit.  The  greater 
destructive  effect  of  the  former  was, 
however,  most  manifest  when  bone 
tissue  was  struck  in  its  course 
through  the  body.  Bone  was  almost 
always  extremely  comminuted,  and 
the  wound  of  exit  caused  by  the 
bullet  after  passage  through  bone 
was  large.  In  the  winter,  at  least, 
many  rifle  bullets,  the  Russian  more 
than  the  Japanese,  were  deformed  by 
striking  hard  ground  or  frozen  walls, 
and  wounds  produced  by  such  bullets 
were  of  course  always  destructive  to 
both  soft  and  bony  tissue  on  account 


of  the  large  wounding  surface  of  the 
missile.  Shrapnel  bullet  wounds 
were  also  always  of  a  severe  charac- 
ter, both  on  account  of  the  large  size 
of  the  shrapnel  bullet  and  because  of 
the  material  of  which  it  was  made — 
soft  lead,  which  is  so  liable  to  defor- 
mation. Wounds  produced  by  pieces 
of  shell  were  even  more  severe,  and 
frightful  injuries  were  caused  by  hand 
grenades.  With  the  last,  tissues  were 
so  lacerated  and  torn  generally  that 
amputation  of  injured  limbs  was 
almost  invariably  required.  Foreign 
bodies  were  not  frequently  carried 
into  wounds  by  the  Japanese  unde- 
formed  bullets,  and  were  still  more 
rare  with  the  Russian  undeformed 
bullets.  With  both  deformed  they 
were  not  uncommon.  The  shrapnel 
ball  also  frequently  drove  foreign 
material  from  the  men's  clothing  into 
wounds.  Fragments  of  shell  some- 
times did  so,  but  often  tore  their  way 
through,  carrying  everything  in  their 
path  before  them.  With  hand  gre- 
nades not  only  were  particles  of  cloth- 
ing sometimes  carried  into  wounds 
by  fragments,  but  stones  and  dirt 
were  frequently  driven  in  by  the 
explosion. 

On  the  whole,  we  may  conclude 
that  the  arms  now  furnished  to  armies 
give  rise  to  injuries  far  more  severe, 
as  a  rule,  than  those  met  with  in  civil 
life,  when  weapons  of  various  kinds, 
imparting  to  bullets  a  much  smaller 
velocity,  are  used.  Shock  is  corre- 
spondingly more  severe,  and  greater 
conservatism,  in  the  remedial  methods 
adopted,  is  necessary. 

Treves,-  Makins  and  Senn  teach  that 
gunshot  wounds  of  the  abdomen  re- 
ceived in  war  do  better  when  let  alone. 
In  civil  life  the  experience  of  all  sur- 
geons   is,    that   those    patients   operated 


152 


ABORTION    (WRIGHT). 


on  promptly  frequently  recover;  those 
treated  expectantly  usually  die.  Five 
personal  cases  in  which  recovery  fol- 
lowed operation  in  4.  Holladay  (N. 
Y.  Med.  Jour.,   Sept.  26,   1908). 

The  general  aim  should  be  to  pre- 
vent infection  by  careful  cleansing  of 
exposed  tissues,  but  also  to  avoid  the 
risk  of  inflicting  additional  injury  by 
injudicious  instrumental  interference 
and  manipulation  of  the  wound. 

Though  the  writer  thinks  the  saying 
of  the  English  surgeon,  that  "A  soldier 
shot  in  the  abdomen  will  live  if  left 
alone  and  will  die  if  operated  upon," 
must  be  taken  cum  grano  salis,  he 
nevertheless  pleads  for  conservative 
treatment.  After  abdominal  gunshot 
injury,  rest  and  absolute  denial  of  food 
and  drink  is  of  prime  importance. 
Every  soldier  should  know  this.  Trans- 
portation, if  necessary,  must  be  done 
carefully.  Treves  reports  that  all  the 
patients  carried  from  a  steep  hill  with 
abdominal  gunshot  injuries  died.  All 
patients  should  be  kept  at  least  eight 
days  in  the  neighborhood  of  the  battle- 
field. For  twenty-four  to  thirty-six 
hours  the  patients  receive  no  food  or 
drink,  then  teaspoonful  doses  of  water, 
tea,  and  gradually  milk.  No  solid  food 
for  fourteen  days.  At  first  much 
morphine  must  be  used.  Persistent 
vomiting  may  be  alleviated  by  lavage, 
provided  the  stomach  is  not  injured. 
Hildebrandt  (Der  Militararzt;  Mili- 
tary Surgeon,  Mar.,  1909). 

The  value  of  laparotomy  for  wounds 
of  the  small  intestine  on  the  battlefield 
almost  unanimously  condemned  in  gen- 
eral discussion  by  military  surgeons. 
In  the  China-Japan,  United  States-Cuba, 
Tirah,  Transvaal,  and  Russia-Japan 
campaigns,  operative  death  was  prac- 
tically universal.  This  is  mainly  be- 
cause facilities  are  lacking  at  the  front, 
while  the  patient  is  frequently  hours  on 
the  ground  before  being  operated. 
Conversely,  spontaneous  recovery  often 
follows  wounds  of  the  intestines  by 
high-velocity  and  small-caliber  bullets. 
The  mucous  membrane  blocks  the  open- 
ing or  muscle-fibers   approximate,   thus 


preventing  the  escape  of  septic  contents. 
This  is  soon  followed  by  formation  of 
adhesions.  Transactions  of  the  Societe 
de  Medecine  Militaire  (Arch,  provin- 
ciales  de  Chir.,  vol.  xviii,  p.  267,  1909). 

Ernest  Laplace, 

Philadelphia. 

ABORTION.— DEFINITION. 

— Abortion  is  the  expulsion  or  removal 
of  the  fructified  ovum  before  the  fe- 
tus is  viable, — meaning  by  the  term 
"viable"  that  the  fetus  has  reached 
such  a  stage  of  development  that  it 
can  live,  thrive  and  grow,  after  birth. 
We  cannot  say  definitely  when  the 
fetus  reaches  that  stage,  but  it  has 
been  the  custom  to  consider  that  it 
becomes  viable  at  the  end  of  the 
seventh  lunar  month  or  the  twenty- 
eighth  week  of  pregnancy. 

Still,  a  very  young  fetus  may  breathe 
after  delivery.  This  occurred,  for  ex- 
ample, in  3  cases  (2  in  the  fifteenth 
and  1  in  the  nineteenth  weeks,  re- 
spectively) reported  by  Glockner.  In 
the  first  of  these  there  were  six  re- 
spiratory movements  before  and  five 
after  severing  the  cord,  the  fetus 
living  one  hour.  In  the  second  case 
the  fetus  lived  an  hour  and  a  half  and 
breathed  five  times.  The  third  fetus 
lived  but  half  an  hour  and  breathed 
eight  times.  The  autopsy  showed  air 
in  the  stomach,  but  the  lungs  were 
empty. 

From  a  clinical  standpoint,  how- 
ever, the  fetus  is  not  viable  before  the 
end  of  the  seventh  calendar  month. 

[It  was  hoped  by  many  a  few  years  ago 
that  by  means  of  the  modern  incubator,  and 
by  a  special  kind  of  feeding  (gavage), 
fetuses  younger  than  twenty-eight  weeks 
might  be  raised.  The  public  were  much  in- 
terested. Ingenious  mechanics  invented 
many  sorts  of  incubators,  some  of  which 
were   very   complicated   and   very  expensive. 


ABORTION    (WRIGHT). 


153 


These  have,  in  the  majority  of  cases,  proved 
very  disappointing.     A.   H.  Wkight.] 

Premature  labor  or  delivery  means 
the  termination  of  pregnancy  between 
the  end  of  the  seventh  month  and  full 
term.  In  certain  cases  it  is  difficult  to 
distinguish  between  late  abortion  and 
early  premature  labor. 

As  to  the  time  of  occurrence,  it  has 
seemed  convenient  to  consider  two 
varieties :  early  abortion,  when  it 
occurs  before  or  about  the  end  of  the 
third  month  of  pregnancy^  and  late 
abortion,  when  it  occurs  between  the 
latter  part  of  the  third  month  and  the 
end  of  the  seventh  month  of  preg- 
nancy. 

Three  varieties  as  to  the  methods 
of  occurrence  are  also  recognized : 
the  spontaneous,  when  the  abortion 
occurs  without  any  outside  interfer- 
ence, and  is  caused  by  some  abnormal 
condition  of  the  mother  or  fetus;  the 
accidental,  when  the  abortion  is  due  to 
accident;  and  the  induced,  when  the 
abortion  is  produced  artificially  by 
interference  from  outside.  Induced 
abortion  is  deemed  legitimate  when 
it  is  produced  by  a  physician  for  just 
cause.  The  cause  is  considered  just 
only  when  the  abortion  is  induced  to 
save  the  mother's  life  which  otherwise 
is  imperiled.  When  the  abortion  is 
induced  without  such  just  cause,  that 
is,  when  it  is  done  for  improper 
or  immoral  reasons,  whether  by  the 
mother  or  the  professional  abortionist, 
it  is  known  both  from  a  medical  and 
legal  standpoint  as  criminal  abortion. 

The  proportion  of  abortions  to  labors 
at  term  from  1898  to  1904,  in  six  of  the 
Maternity  Hospitals  of  Paris,  has  risen 
from  about  5.6  to  about-  16  per  cent. 
More  than  one-half  of  these  cases  are 
provoked  by  criminal  operations  of 
some  kind  or  other.  .  The  proportion 
of  premature  labors  has  also  increased 


considerably.  This  state  of  things  is 
due  to  the  tone  of  modern  novels,  and 
to  the  unhampered  propagation  of  so- 
called  neomalthusian  ideas,  to  books 
and  pamphlets,  published  and  sold 
broadcast,  describing  various  methods 
for  preventing  conception.  Doleris 
(C.  r.  Soc.  obst.,  gyn.,  pa^d.,  Feb.,  1905). 

The  number  of  abortions  requiring 
treatment  in  the  public  hospitals  of 
Paris  is  said  to  have  tripled  during  the 
last  few  years ;  Treub  estimates  the 
criminal  abortions  as  10  per  cent,  of  all 
observed  in  Amsterdam,  and  others 
there  estimate  the  proportion  up  to  33 
per  cent. ;  at  Utrecht,  nearly  14  per 
cent. ;  at  Groningen,  24  per  cent.,  and 
the  author  cites  several  American 
authorities  and  others  to  show^  the  in- 
creasing importance  of  this  subject. 
Warning  against  making  a  local  ex- 
amination of  a  woman  threatened  with 
abortion.  If  absolutely  compelled  to 
make  an  examination,  the  finger  should 
never  be  introduced  until  after  the  ex- 
ternal genitals  have  been  prepared  as 
for  a  vaginal  hysterectomy ;  otherwise, 
puerperal  infection  is  likely  to  ensue 
sooner  or  later  and  the  physician  alone 
will  be  responsible  for  it.  De  Bovis 
(Semaine  medicale,  Oct.  26,  1910). 

Three  cases  of  fatal  mercurial  poison- 
ing from  bichloride  tablets  used  to  pro- 
duce abortion.  In  one  of  these  the 
young  woman  introduced  into  the 
vagina  to  produce  abortion  6  bichloride 
tablets,  each  containing  7.3  grains.  This 
produced  severe  and  burning  pain  and 
such  muscular  spasm  that  the  patient 
could  not  remove  them.  A  physician 
was  promptly  summoned,  who  gave 
vaginal  douches  of  warm  water  and 
morphine  hypodermically.  The  patient 
speedily  developed  intense  symptoms  of 
mercurial  poisoning,  and  died  four  days 
later.  At  autopsy  an  intense  necrotic 
exfoliative  enterocolitis  was  present, 
most  severe  in  the  rectum.  The  proc- 
ess was  distinct  as  high  as  the  duo- 
denum. There  was  also  necrosis  of  the 
muscular  walls  of  the  vagina  and 
vaginal  portion  of  the  cervix.  The 
broad  ligaments.  Fallopian  tubes,  and 
ovaries  were  necrotic,  but  above  the 
internal  os  the  lining  of  the  uterus  was 


154 


ABORTION    (WRIGHT). 


normal.  There  was  no  evidence  of  peri- 
tonitis. Schildecker  (Amer.  Jour,  of 
Obstet.,  March,  1911). 
As  to  frequency,  it  is  impossible  to 
estimate  even  approximately  the  pro- 
portion of  pregnancies  terminating  in 
spontaneous  abortions.  Women  who 
object  to  having  large  families  have 
such  a  multitude  of  expedients  to 
cut  short  their-  pregnancies,  and  fre- 
quently conceal  their  methods  so 
carefully,  that  our  estimates  as  to 
percentages  cannot  be  exact.  From 
the  results  of  our  experience  in  private 
practice  it  is  indicated  that  abortion 
occurs  from  accident  or  spontaneously 
in  1  out  of  10  pregnancies,  that  is, 
10  per  cent.  However,  if  we  include 
induced  abortions  (legitimate  and 
criminal),  it  is  probable  that  abortion 
occurs  in  3  out  of  10  pregnancies,  that 
is,  in  30  per  cent. 

The  figures  of  the  Paris  Maternite 
from  1897  to  1905,  as  collected  by  G. 
Rimette,  show  9875  pregnancies,  1457 
abortions,  627  spontaneous  abortions, 
414  complicated  abortions,  367  infected 
abortions,  and  27  deaths  from  abortion. 
Michailofif,  who  bases  his  figures  on 
257,988  births  in  one  of  the  Russian 
maternities,  found  that  the  proportion 
of  abortions  to  full-term  deliveries 
was  about  1  to  10.  Keyssner,  in  his 
polyclinic  material,  found  469  abortions 
to  2623  confinements,  or  1  to  5.6.  The 
figures  of  hospitals  are  bound  to  be 
faulty,  since  they  omit  the  numerous 
cases  that  are  taken  care  of  at  home. 
Even  polyclinics,  where  the  physician 
attends  the  patients  at  their  home,  do 
not  give  an  accurate  idea  as  to  fre- 
quency, for  many  mothers  have  an 
abortion  with  hardly  an  untoward 
symptom  and  absolutely  without  med- 
ical  attention. 

As  Chazan  points  out,  the  only  ac- 
curate statistics  are  those  obtained 
through  the  patient's  anamnesis.  The 
evidence  thus  far  at  hand  from  such 
sources  is  very  insufificient.  For  this 
reason  the  author  undertook  the  labor 


of  looking  over  the  clinical  records  of 
600  patients  treated  at  the  gynecological 
clinic    of    the    Washington    University 
Hospital.     He    found   that  348  out  of 
these    600   women   had   been    pregnant. 
Of   this   number  there   were   870    full- 
.    term   pregnancies  by   293   mothers,   371 
abortions   by  201   mothers,   36   confess- 
edly criminal  abortions,  50  women  who 
developed     some     gynecologic     disease 
after  abortion.     This  would  make   the 
ratio    of   abortions    to    confinements,   i 
to    2.3.      This   means    that    every   third 
pregnancy  does  not  develop  to  viability, 
a  loss  to  the  world  of  one-third  of  all 
the  children  that  are  conceived.     F.  J. 
Taussig   (Amer.  Jour,  of  Obstet.,  Oct., 
1908). 
Miscarriage. — We  consider  abortion 
and     miscarriage     are      synonymous 
terms.      In    former    times    the    terms 
were  not  considered  so,  nor  are  they 
now  in  some  quarters.     Many,  if  not 
all,   of  the   Rotunda   men,   and   some 
obstetricians  of  North  America,  still 
use  the  term  miscarriage  in  the  old- 
fashioned  way.     According  to  them, 
miscarriage  is  a  term  applied  to  the 
expulsion   of  the   ovum   between   the 
beginning  of  the  fourth  and  the  end  of 
the  seventh  month,  that  is,  between 
the  time  of  the  complete  formation  of 
the   placenta   and   the   time    that   the 
fetus    becomes    viable.      Those    who 
thus  define  miscarriage  say  that  abor- 
tion is  the  term  applied  to  the  expul- 
sion of  the  ovum  before  the  end  of  the 
third  month,  that  is,  before  the  com- 
plete formation  of  the  placenta. 

[It  should  be  remembered  that  a  large 
proportion  of  the  laity  think  that  abortion  is 
the  term  used  when  the  uterus  has  been 
emptied  by  artificial  interference.  It  is  well, 
therefore,  for  the  physician  when  speaking 
to  his  patients  to  use  the  term  miscarriage. 
Some  women  are  offended  if  the  physician 
hints  at  the  possibility  of  their  having  had 
an  abortion.     A.  H.  Wright.] 

SYMPTOMS.— The  symptoms  of 
abortion    are    hemorrhage,    a    brown 


ABORTION    (WRIGHT). 


155 


discharge  after  the  death  of  the  ovum, 
pains  in  the  pelvis,  complete  or  partial 
dilatation  of  the  os  uteri,  expulsion  of 
the  whole  or  part  of  the  ovum. 

The  hemorrhage  in  the  majority  of 
abortions  is  not  profuse,  and  may 
continue  a  long  time.  In  a  certain 
class  of  cases,  however,  the  hemor- 
rhage is  very  profuse  and  sometimes 
causes  death.  Some  think  that  hemor- 
rhage in  earh^  abortion  is  never  pro- 
fuse enough  to  cause  death.  Cer- 
tainly the  hemorrhage  before  the 
formation  of  the  placenta  is  seldom 
dangerous  to  life.  There  are  excep- 
tions to  this  rule,  however;  but,  so  far 
as  we  know,  the  majority  of  the 
fatalities  from  hemorrhage  in  early 
abortion  occur  in  cases  of  criminal 
abortion  where  sharp  or  pointed  in- 
struments are  used. 

Case  of  fatal  hemorrhage  in  a  multip- 
ara of  44  years,  four  months  pregnant. 
The  hemorrhages  had  recurred  daily 
for  eight  weeks,  but  were  severe  only 
during  the  last  two  weeks,  causing 
marked  anemia  and  exhaustion.  The 
uterus  was  emptied  under  anesthesia 
after  dilatation  of  the  uterus,  but  this 
was  followed  by  bleeding  which  hot 
irrigation,  saline  solution,  massage,  or 
tamponing  failed  to  control.  The 
uterus  was  then  removed  through  the 
vagina  in  nine  minutes,  but,  although  no 
blood  was  lost,  the  patient  gradually 
sank.  Careful  macroscopic  and  micro- 
scopic examination  of  the  organ  failed 
to  reveal  any  morbid  condition  of  any 
kind.  Henze  (Zentralbl.  fiir  Gynak., 
Nu.  29,   1908). 

In  considering  the  symptomatology 
of  abortion,  however,  it  is  very  im- 
portant to  obtain  a  clear  conception  of 
the  two  varieties  commonly  recognized, 
viz. :  the  "threatened"  and  the  "in- 
evitable." 

[The  importance  of  this  distinction  asserts 
itself  in  connection  with  treatment.  In  the 
case  of  threatened  abortion  we  are  in  doubt 


as  to  whether  the  uterus  will  be  emptied  or 
not,  and  our  treatment  aims  at  controlling 
the  influences  which  are  producing  the  symp- 
toms of  abortion,  such  as  hemorrhage  and 
uterine  contractions.  In  the  case  of  inevi- 
table abortion  the  contents  of  the  uterus  will 
be  held  or  partially  expelled  by  nature's 
efforts,  and  we  pursue  a  line  of  treatment 
entirely  different  from  that  adopted  for 
threatened  abortion.  Our  aim  now  is  to  as- 
sist nature  in  expelling  the  contents  of  the 
uterus  as  soon  as  possible  with  safety  to  the 
mother.     A.  H.  Wright.] 

The  symptoms  of  threatened  abor- 
tion are  hemorrhage,  pelvic  pain  and 
perhaps  a  slight  dilatation  of  the  os, 
especially  in  multiparse.  The  hemor- 
rhage, as  already  mentioned,  is  com- 
paratively slight  in  a  large  proportion 
of  cases,  and  may  continue  for  nine  or 
ten  weeks  or  longer  without  ending 
in  actual  abortion.  The  pains  which 
are  caused  by  uterine  contractions 
may  be  fairly  severe  and  may  con- 
tinue for  -some  time  without  causing 
the  expulsion  of  the  ovum. 

External  hemorrhage  is  not  only  the 
most  important,  but  the  most  common 
premonitory  symptom  of  abortion,  and 
although  it  may  be  induced,  atony  of 
the  uterus  is  its  most  frequent  cause. 
Under  such  circumstances  it  may  appear 
as  early  as  the  sixth  week  of  pregnancy, 
about  the  time  when  the  serotinal  ves- 
sels begin  to  undergo  rapid  enlargement 
in  response  to  the  stimulation  of  the 
placental  chorion.  Hemorrhage  may 
also  be  due  to  deficiency  of  calcium  and 
potassium  in  the  muscular  substance  of 
the  uterus,  or  to  the  presence  of  some 
toxic  material  impairing  the  tone  and 
responsive  power  of  the  organ.  In  such 
cases  potassium  iodide  and  calcium 
chloride  are  given  to  remove  deleterious 
substances  or  to  supply  those  which  are 
deficient.  When  the  muscular  energy 
of  the  uterus  is  impaired  there  is  often 
enfeeblement  of  the  nerve  energy  also, 
and  strychnine,  arsenic,  digitalis,  or 
phosphorus  may  be  given  with  benefit. 
Pain  is  the  other  all-important  prodro- 
mal symptom  of  abortion.     It  may  be 


156 


ABORTION    (WRIGHT). 


noted  when  the  uterus  does  not  ade- 
quately respond  to  and  fails  to  expand 
correlatively  with  the  developing  ovum. 
The  uterine  tissues,  again,  may  be  re- 
sponsive enough,  but  they  may  be  re- 
strained by  adhesions.  Abortion  not 
infrequently  results  from  physical  or 
mental  shock,  or  a  combination  of  both 
influences.  After  the  tenth  or  twelfth 
week  of  pregnancy  the  uterus  may  be 
injured  directly  by  a  blow  on  the  lower 
abdomen,  and  abortion  may  more  or 
less  quickly  ensue.  But  usually  there 
is  extravasation  of  blood  from  rupture 
of  the  functionally  active  maternal  ves- 
sels;  the  blood  may  never  make  its 
escape  externally,  and  pain  may  be  the 
only  symptom.  No  drugs  should  be 
given  in  such  cases;  absolute  rest  is 
the  best  treatment.  Necrosis  of  the 
amniochorion  is  a  very  rare  cause  of 
abortion,  and  it  determines  this  event 
by  allowing  the  amniotic  fluid  to  escape. 
J.  Oliver  (Brit.  Med.  Jour.,  Nov.  30, 
1907). 

In  inevitable  abortion  there  are  also 
hemorrhage,  pelvic  pains  and  more 
or  less  dilatation  of  the  os,  but  these 
phenomena  are  more  severe  and  pro- 
nounced. It  is  sometimes,  in  fact, 
very  difficult  to  decide  when  an  abor- 
tion becomes  inevitable.  Probably 
the  safest  guide  is  the  hemorrhage. 
If  the  fetus  is  dead,  or  if  the  mem- 
branes are  ruptured,  abortion  is  also 
deemed  inevitable.  No  definite  rules 
can  be  given  in  this  regard. 

That  abortion  is  inevitable  when  the 
membranes  are  ruptured  is  generally 
believed  to  be  true  in  every  case,  but 
3  personal  cases  have  proven  to  be 
exceptions.  In  the  first,  a'  young 
woman  in  her  first  pregnancy,  a  fall 
caused  rupture  of  the  membranes  at 
about  the  end  of  the  sixth  month ;  a 
large  quantity  of  amniotic  fluid  escaped, 
and  pains  came  on  with  some  dilata- 
tion of  the  OS.  With  rest  in  bed  and 
a  free  use  of  viburnum  the  patient  re- 
covered and  went  on  to  end  of  seventh 
month,  when  there  were  pains  again ; 
the  same  treatment  was  followed  by  the 


same  result,  and  the  writer  delivered 
her  at  full  time  of  a  healthy  boy.  In 
the  second  case  the  membranes  rup- 
tured during  the  eighth  month,  but  was 
not  delivered  until  the  end  of  the  full 
term  of  a  living,  healthy  boy.  In  the 
third  case  the  membranes  had  ruptured 
three  weeks  before  the  present  writing 
and  had  not  delivered  yet.  J.  R.  N. 
Smith  (Communication  to  the  Editor, 
1908). 

[This  communication  is  interesting,  but  the 
writer  furnishes  no  evidence  to  show  that 
the  discharge  of  the  fluid  in  any  of  the  3 
cases  was  due  to  rupture  of  the  mem- 
branes. It  seems  probable  that  the  discharge 
of  watery  fluid  in  each  instance  was  due  to 
that  mysterious  condition  the  nature  of 
which  we  know  but  little  about — hydrorrhoea 
gravidarum,  or  decidual  endometritis.  A. 
H.  Wright.] 

The  symptomatology  of  abortion 
varies,  of  course,  to  a  certain  extent 
according  to  the  time  at  w^hich  it 
occurs.  As  carefully  collated  by  Lu- 
taud,  of  Paris,  the  symptoms  at  the 
different  periods  are  briefly  as  fol- 
lows : — 

Abortion  During  the  First  Month. 
— This  usually  gives  rise  to  symptoms 
simulating  those  of  retarded  menstru- 
ation. Slight  pains  in  the  back  in  the 
region  of  the  uterus  are  complained 
of;  the  symptoms,  in  this  particular, 
resemble  those  of  normal  labor,  but 
are  very  much  less  marked.  Blood, 
blood-clots,  and  flakes  of  the  mucous 
membrane  of  the  uterus  are  gradually 
expelled  during  several  days.  The 
ovum  is  expelled  entire,  but  it  is  so 
small  that  it  is  rarely  discovered. 

Abortion  During  the  Second  Month. 
— Inasmuch  as  the  uterus  has  de- 
cidedly increased  in  size  as  compared 
with  its  size  in  the  first  month,  the 
contractions  and  pains  are  compara- 
tively stronger.  The  embro  is  usu- 
ally expelled  inclosed  in  the  unbroken 


ABORTION    (WRIGHT). 


157 


membranes.  Sometimes,  however, 
the  latter  are  ruptured. 

The  embryo  and  membranes  may 
be  detached  from  the  uterus  in  two 
ways : — 

(a)  P)}'  hemorrhage  between  the 
membranes  and  the  uterus^  followed 
by  uterine  contraction. 

{b)  By  contraction  of  the  uterus, 
followed  by  hemorrhage.  In  the  lat- 
ter case  the  abortion  is  more  pro- 
longed, the  membranes  being  de- 
tached but  slowly  from  the  uterus. 

If  the  embryo  be  still  living,  the 
abortion  lasts  longer,  and  the  hemor- 
rhage is  greater.  If  the  embryo  be 
dead,  the  whole  is  usually  expelled 
like  a  foreign  body,  and  without  rup- 
ture of  the  membranes. 

Examination  of  the  uterus  will 
show  that  it  is  increased  in  volume 
and  situated  lower  down  in  the  pelvis 
than  normally.  The  cervix  is  dilated, 
softened,  and  filled  with  blood-clots. 
The  dilatation  is  more  marked  in 
multiparse  than  in  primiparse. 

The  cervix,  though  dilated,  does 
not  become  effaced,  and  the  embryo 
contained  in  the  unruptured  mem- 
branes may  pass  through  the  cervix 
and  be  expelled.  If  the  membranes 
are  ruptured,  however,  the  embryo 
passes  by  itself,  the  very  thin  umbili- 
cal cord  breaks,  and  the  cervix  closes. 
The  membranes  are,  in  this  latter 
case,  expelled  later  on.  The  mem- 
branes are  ruptured  about  once  in 
every  2  cases. 

Abortion  from  the  Beginning  of  the 
Third  to  the  End  of  the  Fourth 
Month. — This  occurs  nearly  always  in 
two  stages,  the  first  consisting  in  the 
expulsion  of  the  fetus,  and  the  second 
in  the  expulsion  of  the  membranes 
and  placenta. 

The  cervix  in  this  form  of  abortion 


tends  to  diminish  in  length.  The 
uterine  contractions  act  more  power- 
fully than  in  the  previous  forms  of 
abortion.  Under  their  influence  the 
membranes  are  ruptured  and  the  fetus 
is  expelled. 

The  placenta  may  still  be  adherent ; 
the  cervix  then  closes  again,  and 
the  placenta  and  membranes  are  ex- 
pelled later  on.  Hemorrhage  is  likely 
to  accompany  the  delivery  of  the 
placenta  and  membranes,  especially 
when  the  former  is  only  partly  de- 
tached. Under  these  circumstances 
each  uterine  contraction  is  accompa- 
nied by  hemorrhage. 

The  placenta  may  be  already  de- 
tached when  the  fetus  is  expelled;  in 
such  a  case  it  is  likely  to  be  expelled 
immediately  after  the  latter,  before 
the  cervix  closes,  but  part  of  the 
decidua  may  remain  in  the  uterus 
after  delivery  of  the  placenta.  This 
occurs  most .  frequently  when  the 
fetus  is  dead. 

Statistics  show  that  retention  of  the 
placenta  occurs  most  frequently  dur- 
ing this  period. 

Abortion  During  the  Fifth  and 
Sixth  Months. — The  fetus  and  pla- 
centa are  almost  always  expelled  sep- 
arately. Uterine  contraction  is  more 
marked;  the  cervix  tends  to  become 
more  effaced  and  to  dilate. 

Delivery  of  the  placenta  usually  fol- 
lows delivery  of  the  fetus  rapidly,  and 
the  tendency  to  hemorrhage  is  less 
marked  than  in  the  previous  forms  of 
abortion. 

Of  501  cases  of  abortion  analyzed 
by  Varnier  and  Brion,  the  fetus,  or 
embryo,  and  the  placenta  were  ex- 
pelled separately  in  453,  and  together 
in  48  cases.  When  the  delivery  oc- 
curred in  two  stages,  the  time  found 
to  elapse  between  the  expulsion  of  the 


158 


ABORTION    (WRIGHT). 


fetus  and  that  of  the  placenta  was  as 
follows:  120  cases,  within  15  min- 
utes; 81  cases,  from  15  to  30  minutes; 
78  cases,  from  30  to  60  minutes;  83 
cases,  from  1  to  4  hours. 

AVhenever  the  placenta  and  mem- 
branes are  not  expelled  within  four 
hours  after  the  expulsion  of  the  fetus, 
or  embryo,  there  is  retention  of  the 
membranes  and  placenta. 

Abortion  may  take  place  suddenly, 
or  resemble,  in  that  particular,  the 
irregular  periodicity  of  normal  labor, 
with  more  or  less  hemorrhage.  It 
may,  indeed,  last  several  days,  owing 
to  weakness  of  the  uterine  contrac- 
tions or  adhesions  to  the  uterus  or 
retention  in  the  cervix  of  the  masses 
to  be  expelled.  (Rokitansky,  Schii- 
lein.) 

Sudden  or  rapid  abortion  is  frequent 
during  the  first  two  months;  when 
the  expulsion  takes  place  after  the 
third  month  it  generally  presents  the 
characters  of  normal  delivery. 

The  menstruation  returns  earlier 
after  abortion  than  after  a  normal 
labor.  Englander,  in  a  recent  (1906) 
study  of  57  cases  of  abortion,  under- 
taken to  ascertain  the  period  of  their 
first  subsequent  menstruation,  found 
that  in  64.9  per  cent,  the  menses  re- 
appeared in  four  weeks ;  in  five  weeks 
in  14  per  cent.  The  remainder  varied, 
1  patient  going  as  long  as  six  weeks 
after  the  abortion  before  menstru- 
ating. After  labor,  it  is  usually  six 
to  eight  weeks  before  patients  men- 
struate. 

DANGERS.— Just  as  parturition 
may  be  attended  by  deviations  from  the 
normal,  so  may  abortion. 

Retention  of  the  placenta  occurs  fre- 
quently. The  latter  is  sometimes  ex- 
pelled safely  after  some  days,  either 
entire  or  in  pieces,  but  prolonged  re- 


tention exposes  the  patient  to  hemof- 
rhage,  toxemia,  and  septicemia.  When 
completely  detached,  though  retained, 
the  placenta  gives  rise  to  no  hemor- 
rhage, but  if  only  partially  detached 
such  is  not  the  case  and  copious  hem- 
orrhage may  thus  be  produced. 

In  15,000  cases  of  abortion,  fever  oc- 
curred in  IS  per  cent.  Of  633  patients, 
182  had  chills  before  they  came  under 
active  treatment.  Among  the  15,000 
patients  were  450  who  were  severely 
infected;  of  these  94  died.  In  82  cases 
autopsy  was  made.  Those  cases  showed 
the  most  severe  symptoms  in  which  the 
longest  time  elapsed  before  the  uterus 
was  completely  emptied.  Fever  often 
ceased  when  the  uterine  contents  were 
expelled.  These  were  cases  of  pure 
sapremia  in  which  the  bacilli  present 
were  only  mildly  infective.  It  is  of  the 
utmost  importance  that  no  artificial 
wound  be  made  in  the  lining  membrane 
of  the  uterus.  In  these  cases  neither 
incision  nor  forcible  dilatation  should 
be  practised,  but  if  necessary  the  cervix 
should  be  tamponed  with  gauze  until 
the  uterus  is  sufficiently  open  to  permit 
the  removal  of  its  contents  with  the 
finger.  No  sharp  instrument  should  be 
■employed  in  the  treatment  of  abortion. 
Seegert  (Zeit.  f.  Geb.  u.  Gyn.,  Bd.  Ivii, 
H.  3,  1906). 

The  general  symptoms  that  follow 
hemorrhage  (a  weak  pulse,  vertigo, 
fainting,  etc.)  occur  only  when  the  loss 
of  blood  has  been  severe.  Under  these 
conditions  septicemia,  as  evidenced  by 
fetid  lochia,  chills,  and  high  tempera- 
ture, is  a  probable  complication.  En- 
dometritis, salpingitis,  and  peritonitis 
have  also  been  witnessed  under  such 
conditions.  Tetanus  is  also  another 
possible  complication  of  these  cases. 

Case  of  tetanus  after  abortion.  The 
latter  occurred  during  the  third  month. 
The  uterus  was  properly  cleared,  but 
on  the  ninth  day  the  temperature  rose, 
then  fell  after  an  injection  of  collargo- 
lin.  Trismus  was  observed  on  the  next 
day,   followed  by  tetanus,  which  grew 


ABORTION    (WRIGHT). 


159 


worse  till  the  fifteenth  day.  Nunicrous 
injections  of  Behring's  tetanus  anti- 
toxin were  administered,  and  recovery 
followed.  Osterloh  (Monats.  f.  Geb. 
u.  Gyn.,  Aug.,  1902). 

ETIOLOGY  AND  PATHOGEN- 
ESIS.— There  has  been  much  theoriz- 
ing as  to  the  causes  of  abortion,  and 
in  man}^  instances,  the  explanations 
and  complicated  classifications  vouch- 
safed have  obscured  the  subject  in- 
stead of  elucidating  it. 

The  causes  of  abortion  are  usually 
considered  in  an  unsystematic  and 
illogical  way.  We  should  differentiate 
between  conditions  of  the  uterus  which 
predispose  to  expulsion  of  the  ovum 
and  conditions  which  excite  the  uterus 
to  get  rid  of  its  contents.  The  predis- 
posing causes  are  :  1.  Increased  sensi- 
tiveness to  nerve  irritation  (tempera- 
ment, frequent  abortions,  menstrual 
period).  2.  Greater  tendency  to  pla- 
cental thrombosis  (inflammation  of 
endometrium,  congestion).  3.  Lessened 
resistance  to  expulsion  (cervical  tears 
or  amputation). 

The  exciting  causes  are :  1.  Mechan- 
ical Irritation:  (a)  transmitted  (blow, 
fall,  dancing,  railroad  journey,  lifting 
heavy  objects,  constipation)  ;  (b)  direct, 
(1)  to  outside  of  uterus  (adhesions, 
malposition,  tumors,  examination,  lapa- 
rotomy) ;  (2)  to  inside  of  uterus  (in- 
struments, hemorrhagic  exudates,  hy- 
dramnios,  tumors). 

2.  Thermic  Irritation:  (a)  general 
(sea-bath)  ;  (b)  local  (hot  douche, 
sitz-bath). 

3.  Toxic  Irritation-:  (a)  chemical 
toxins  (ergot,  carbon  dioxide,  lead 
poisoning)  ;  (b)  bacterial  toxins  (ma- 
ternal small-pox,  measles,  etc.)  ;  (c) 
placental  toxins,  hyperemesis,  chorea, 
eclampsia. 

4.  Nerve  Irritation:  (a)  psychic 
(fright,  pain,  shock)  ;  (b)  reflex  (ex- 
ternal  genitals,  breast,   nose). 

5.  Death  of  Fetus:  (a)  congenital 
inanition  (illness  bf  parents,  alcoholism, 
too  frequent  coitus)  ;  (b)  congenital 
deformities  (primary  in  ovum,  amniotic 
adhesions)  ;    (c)   interference  with  nu- 


trition :  (1)  maternal  (anemia,  tuber- 
culosis) ;  (2)  placental  (mole  degen- 
eration, thrombosis)  ;  (3)  umbilical 
(twisted  cord,  true  knot,  constrictions)  ; 
((/)  infectious  diseases  (syphilis,  small- 
pox, typhoid,  pneumonia,  etc.)  ;  (e) 
hyperpyrexia.  Taussig  (Amer.  Jour, 
of  Obstet.,  Oct.,   1908). 

Series  of  cases  from  Aschoff's  insti- 
tute in  Freiburg  in  which  specimens  of 
Fallopian  tubes  removed  after  cases  of 
abortion  were  examined  It  was  found 
that  after  a  normal  pregnancy  in 
labor  there  was  no  inflammatory  re- 
action in  the  Fallopian  tubes,  but  that 
after  dilatation  of  the  cervix  with 
laminary  tents,  although  careful  asepsis 
had  been  employed  in  a  large  majority 
of  cases,  there  was  an  inflammation  of 
the  tube  which  had  gone  on  to  purulent 
salpingitis  and  lymphangitis.  This  path- 
ological observation  is  increased  evi- 
dence of  the  difficulty  of  conducting 
vaginal  operations  aseptically.  Amers- 
bach  (Monatssch.  fiir  Geburts.  u. 
Gynak.,  Bd.  xxxii,  Hft.  4,  1910). 

It  is  generally  recognized,  however, 
that  the  causes  may  be  of  maternal, 
paternal,  and  fetal  origin. 

Maternal  Causes. — Most  cases  of 
abortion  are  generally  attributed  to 
traumatisms,  falls,  blows — a  cause  not 
infrequently  met  with  in  the  slums — 
the  likelihood  of  premature  delivery 
being  decreased  in  proportion  as  the 
blow  or  other  injury  is  remote  from 
the  region  of  the  uterus.  Operations, 
even  sometimes  when  insignificant, 
have  produced  abortion.  The  so- 
called  "aborting  habit"  is  also  recog- 
nized as  a  potent  factor  in  this  con- 
nection; but  this  expression  doubtless 
covers,  in  most  instances,  some  hidden 
and  probably  removable  cause. 

In  most  cases  the  actual  cause  of  a 
miscarriage  escapes  observation.  Com- 
monly it  is  attributed  to  a  vague  trau- 
matism; often  to  a  fall  on  the  stairs. 
In  reality  the  pathogeny  of  abortion  is 
as  follows :  The  ovum  plays  the  part 
of  a  foreign  body  and  is  expelled,  first, 


160 


ABORTION    (WRIGHT). 


when  it  is  itself  changed  by  death, 
separation,  or  other  cause,  though  con- 
tained in  a  normal  uterus ;  second, 
when,  whether  healthy  or  not,  it  is  con- 
tained in  an  intolerant  uterus.  The 
causes  which  may  produce  these  con- 
ditions are  changes  in  the  ovum,  patho- 
logical conditions  in  the  uterus,  faults 
in  the  general  health  of  the  woman, 
and  vitiation  of  the  spermatozoa.  Trau- 
matism varies  greatly  in  its  power  to 
interrupt  pregnancy  according  to  its 
intensity,  the  seat  of  its  application,  its 
severity  and  repetition,  the  age  of  the 
fetus,  and  the  degree  of  the  idiosyn- 
cratic irritability  of  the  uterus.  Bon- 
naire   (Presse  medical.  May  3,  1905). 

The  predominating-  cause,  however, 
according  to  statistics^  is  syphilis,  to 
which  are  attributed  over  one-fourth 
of  the  "cases.  When  it  is  contracted 
before  conception,  abortion  occurs  re- 
peatedly— early  when  the  infection  is 
of  recent  date,  but  gradually  nearer 
term  as  the  contamination  is  more 
remote.  There  comes  a  time,  there- 
fore, when  normal  delivery  becomes 
possible. 

Next  in  order  are  malpositions  and 
inflammatory  disorders  and  tumors  of 
the  uterus  and  its  adnexa,  including 
ovarian  cysts.  Laceration  of  the  cer- 
vix has  recently  attracted  attention  as 
a  cause  of  abortion.  The  tear  may  be 
limited  to  the  cervix,  or  it  may  extend 
upward  to  the  body  of  the  organ;  or 
again  the  rupture  may  occur  above 
the  external  os. 

Charpentier  refers  to  three  distinct 
local  uterine  conditions  in  otherwise 
healthy  women:  1.  Ill-developed  uter- 
us ;  the  muscular  coat  does  not  readily 
soften,  yet  remains  very  irritable. 
Rare.  2.  Displacements,  especially 
flexions.  Spur  at  the  angle  of  flexion 
hypertrophies  interferes  with  uterine 
development.  3.  Congestion  of  the 
body  and  cervix,  due  to  idiosyncrasies. 
Endometritis. 


Lacerations  of  the  cervix,  especially 
those  of  some  depth,  are  a  frequent 
cause  of  abortion.  A  primipara  can 
usually  give  some  cause  for  an  abor- 
tion, such  as  a  misstep  or  a  fall,  but 
in  those  who  have  previously  borne 
children,  where  there  is  a  fissure  ex- 
tending as  high  as  the  internal  os  that 
will  admit  the  tip  of  the  index  finger, 
or  the  integrity  of  the  lower  uterine 
segments  is  lost,  predisposition  to  abor- 
tion is  undoubted.  R.  W.  Rogers 
(Montreal  Med.   Jour.,  April,   1902). 

One  of  the  rarer  causes  of  abortion 
is  laceration  of  the  cervix;  but  if  the 
laceration  is  repaired  a  subsequent 
pregnancy  will  often  proceed  to  term, 
as  the  writer  has  seen  happen  twice  in 
11  cases.  Among  other  causes  of 
habitual  abortion  not  generally  known 
are  residues  of  past  inflammation  of 
the  pelvic  peritoneum,  three  or  four 
instances  of  which  he  has  met  with. 
Sterility  is  usually  associated  with  exu- 
dations in  the  parametrium,  and  even 
should  conception  occur  the  pregnancy 
seldom  persists  to  term.  The  writer 
has  also  seen  abortion  due  to  fibroma 
of  the  uterus,  four  times ;  to  heart 
disease,  three  times ;  to  diabetes  mel- 
litus,  twice ;  to  hydramnios  in  two  in- 
stances, and  to  pulmonary  emphysema 
in  one.  Kleinwaechter  (Zeit.  f.  Geb.  u. 
Gyn.,  Bd.  xlix,  H.  i,  1903). 

Case  of  a  primigravida,  in  whom  it 
was  necessary  to  terminate  an  early 
pregnancy.  Iodoform  gauze  was  intro- 
duced into  the  cervix,  followed  by  the 
development  of  considerable  pain.  The 
temperature  rose  also ;  the  pulse  in- 
creased in  frequency;  the  uterus  be- 
came very  sensitive,  and  there  was  a 
fetid  mucous  discharge.  To  hasten  the 
emptying  of  the  uterus,  tents  and  bou- 
gies were  used.  This  was  followed  by 
increase  in  pain.  Twenty-four  hours 
afterward  examination  showed  that  the 
cervix  had  not  dilated,  but  had  rup- 
tured above  the  external  os.  It  was 
necessary  to  empty  the  uterus  com- 
pletely under  anesthesia  and  to  remove 
portions  of  the  cervix  which  had  al- 
ready been  torn.  The  patient  recov- 
ered, the  tears  healing  by  granulation. 
Blumreich  (Zentralbl.  f.  Gyn.,  Nu.  29, 
1907). 


ABORTION    (WRIGHT). 


161 


Debilitating  influences  of  various 
kinds,  such  as  insufficient  food,  ex- 
cessive pliysical  labor  or  fatigue,  men- 
tal and  physical  shock,  the  abuse  of 
alcohol,  tobacco  (women  employed  in 
cigar,  cigarette,  etc.,  factories),  car- 
bonic oxide  (as  shown  by  the  frequent 
occurrence  of  abortion  in  cooks)  and 
lead,  including  paternal  intoxication 
by  this  metal,  tend  also  to  bring  on 
miscarriage. 

In  south  Yorkshire  10  out  of  IS 
women  who  suffered  from  lead  poison- 
ing admitted  that  they  had  used  lead 
as  an  abortifacient.  In  11  of  the 
case?  abortion  had  actually  occurred. 
The  fact  is  important,  and  shows  that 
lead  poisoning  must  be  kept  in  mind 
when  such  symptoms  as  abdominal 
pain,  vomiting,  and  constipation  are 
present  in  women  who  are  supposed  to 
be  pregnant.  Thomson  and  Littlejohn 
(Edinburgh  Med.  Jour.,  June,  1905). 

Great   shock   or   injury   is   sometimes 
better  borne  by  pregnant  women  than 
frequently  repeated  shock,  e.g.,  the  use 
of  the   sewing  machine  with  the    foot. 
The    author    reports    cases    illustrating 
the  fact  that  motoring  during  the  early 
months  of  pregnancy  is  frequently  fol- 
lowed by  abortion.     The  danger  seems 
to  lie  in  the  fact  that  the  rapid  motion 
of  a  motor  car  subjects  the  patient  to 
many  small,    frequent  jars.     The   char- 
acteristic of  abortion   following  motor- 
ing is  its   slow   and   insidious   develop- 
ment   without    bright    hemorrhage    or 
pain.     These   abortions    are,    as   a   rule, 
incomplete,  and  require  curetting.    While 
motoring   is    dangerous   in    early   preg- 
nancy, in  the  later  months  of  gesta- 
tion and  with  reasonable  precautions 
as  to  smoothness  of  roads  and  mod- 
eration   of    speed    it    may    prove    ex- 
ceedingly    useful.       Davis     (Medical 
Record,  Jan.  30,  1909). 
Debilitating  diseases  have  also  been 
found    to    induce    it.      Influenza,    in 
which  the  general  adynamia  is  marked, 
has    been    recorded    as    a    cause.     In 
Asiatic    cholera,    abortion    is  -almost 
invariably  produced. 


Conversely,  conditions  which  tend 
to  exaggerate  the  contractility  of  the 
uterine  muscle  are  also  recognized 
causes.  Ergot,  copper  sulphate  and 
other  "abortifacients"  are  familiar 
agents  of  this  class.  This  evil  action 
has  also  been  attributed  to  quinine, 
but  there  is  reason  to  believe  that  this 
valuable  remedy  should  not  be  with- 
held in  pregnant  women,  when  in- 
dicated therapeutically,  especially  in 
view  of  the  fact  that  malaria  itself 
tends  to  cause  abortion.  Thus,  in  a 
study  of  the  action  of  quinine  on 
pregnant  women,  Frederici  found  that 
in  49  pregnancies  quinine  had  been 
used  in  47,  the  patients  suffering  more 
or  less  severely  from  malarial  fever ; 
47  terminated  at  the  usual  period  by 
the  birth  of  a  child,  and  2  aborted. 
In  these  2  cases  he  deems  it  extremely 
probable  that  the  high  fever  from 
which  they  suffered  was  instrumental 
in  producing  abortion.  He  concluded 
that  medicinal  doses  of  quinine  were 
powerless  to  induce  abortion. 

Case  of  a  hospital  nurse,  pregnant 
two  months,  who  attempted  to  induce 
abortion  by  injecting  into  the  uterus 
1  gram  of  Fehling's  solution.  She 
reported  her  act  within  half  an  hour. 
The  symptoms  she  then  presented  were 
extreme  anxiety,  coolness  of  the  skin, 
and  decided  slowness  of  the  pulse. 
There  was  no  bleeding.  The  following 
day  the  pulse  had  become  improved, 
there  was  considerable  vomiting,  and 
the  urine  was  extremely  dark.  The 
urine  gradually  became  bloody,  and  at 
the  end  of  five  days  showed  many  casts. 
All  the  toxic  symptoms  gradually  dis- 
appeared, but  no  abortion  took  place. 
Tantzscher  (Zentralbl.  f.  innere  Med., 
Jan.  5,  1907). 

Infectious  diseases  provoke  abor- 
tion in  a  large  proportion  of  cases 
when  the  febrile  period  is  reached.  It 
occurs  in  about  two-thirds  of  preg- 


1—11 


162 


ABORTION    (WRIGHT). 


nant  women  attacked  by  typhoid 
fever,  especially  during  the  earlier 
months.  Uterine  hemorrhage  is  usu- 
ally the  first  symptom  observed.  Thus 
Sacquin  colFected  310  cases,  and  found 
abortion  in  199;  while  Martinet  found 
66  abortions  in  109  cases. 

Small-pox  causes  abortion  in  about 
40  per  cent,  of  the  pregnant  women  it 
attacks  and  the  mortality  is  about  50 
per  cent.,  but  is  nearly  100  per  cent. 
in  the  confluent  type.  In  varioloid 
the  child  sometimes  remains  unaf- 
fected. The  disease  may  also  develop 
during  convalescence.  Abortion  dur- 
ing variola  is  apt  to  be  attended  with 
more  than  the  ordinary  hemorrhage. 

Arnaud  has  reported  several  serious 
cases  occurring  during  convalescence 
after  small-pox.  The  grave  symp- 
toms are  attributed  to  the  retention 
of  the  fetus,  which  died  during  the 
acute  stage  of  small-pox,  and  was  fre- 
quently only  expelled  during  or  after 
convalescence. 

Measles  is  an  infrequent  complica- 
tion of  pregnancy,  but,  as  observed 
by  KlotZj  it  causes  abortion  in  the 
majority  of  such  instances.  Pneu- 
monia frequently  appears  as  an  addi- 
tional complication.  Scarlatina  is 
also  infrequently  observed  in  preg- 
nant women,  though  it  is  commonly 
observed  during  the  parturient  state. 

Pneumonia  causes  abortion  in  about 
one-third  of  the  pregnant  women  it 
attacks  early  and  in  two-thirds  of 
those  which  contract  the  disease  late. 
In  the  latter  cases  the  fetus,  though 
viable  when  born,  may  soon  die  of 
the  infection  after  birth.  The  sta- 
tistics of  213  cases  of  pneumonia 
during  pregnancy  published  by  Flatte 
showed  that  the  pregnancy  was  inter- 
rupted in  118  cases,  there  being  42 
abortions  and  76  premature  deliveries. 


Death  of  the  mother  occurred  in  75 
cases  among  the  213:  a  mortality  of 
35  per  cent.  The  mortality  of  the 
mother  was  greater  in  premature  de- 
liveries than  in  abortion. 

Pulmonary  tuberculosis,  owing  to 
its  exhausting  influence  upon  the  nu- 
tritional resources  of  the  body,  renders 
it  unfit  to  carry  the  fetus  to  term  when 
the  morbid  process  is  far  advanced. 
Abortion  is  relatively  frequent  in  such 
cases,  its  occurrence  and  the  viability 
of  the  child  depending  upon  the  stage 
of  the  disease. 

Chorea,  though  a  rare  complication 
of  pregnancy,  causes  abortion  in  one- 
half  of  the  cases,  and  is  especially 
observed  in  primiparse.  If  the  de- 
livery occurs  sufficiently  late,  the  child 
may  live,  but  is  frequently,  affected 
with  chorea.  The  chorea  sometimes 
ceases  after  delivery. 

Cardiac  diseases  influence  preg- 
nancy when  it  is  sufficiently  marked 
to  impair  the  general  circulation. 
Acute  pericarditis  practically  has  no 
morbid  influence  on  gestation,  but 
chronic  pericarditis  is  deemed  per- 
nicious. Acute  endocarditis  assumes 
increased  virulence  during  pregnancy, 
its  tendency  being  to  become  ulcera- 
tive, and  to  entail  a  fatal  ending. 

Icterus,  in  its  various  forms,  some- 
times complicates  pregnancy.  Even 
simple  catarrhal  icterus  may  cause 
abortion,  but  in  icterus  gravis  it 
occurs  always  and  usually  proves 
fatal.  In  the  epidemic  icterus  of  preg- 
nancy, the  probability  that  abortion 
will  occur  is  somewhat  smaller,  while 
the  mortality  is  not  as  great.  Preg- 
nancy not  only  aggravates  even  sim- 
ple icterus,  but  it  increases  the  tend- 
ency to  yellow  atrophy  of  the  liver. 

Paternal  and  Fetal  Causes. — The 
influence  of  syphilis  on  abortion  has 


ABORTION    (WRIGHT). 


163 


been  reviewed;  in  most  instances  it  is 
acquired  from  the  male  directly,  either 
before  or  after  conception,  the  disease 
being  communicated  to  the  fetus,  in 
the  latter  case,  through  the  placenta. 
In  accord  with  Colles's  law,  the  fetus 
may,  as  is  well  known,  inherit  the 
paternal  syphilis,  while  the  mother  re- 
mains immune.  Abortion  may  thus 
be  caused  through  maternal  or  fetal 
S3-philis  acquired  from  the  father. 

Any  condition  such  as  senility,  al- 
coholism, overwork,  etc.,  which  tends 
to  lower  the  vitality  of  the  father  tends 
also  to  weaken  the  offspring  and  pro- 
mote the  tendency  to  miscarriage  in  the 
mother.  Certain  occupations  which 
expose  the  patient  to  the  action  of 
certain  poisons,  mercury,  phosphorus, 
or  lead,  for  instance,  tend  in  the  same 
direction. 

Besides  the  features  which  tend  to 
compromise  the  development  of  the 
fetus  that  have  been  referred  to,  it  is 
itself  subject  to  injuries  communi- 
cated from  the  exterior,  blows,  shocks, 
penetrating  wounds  (knife,  bullets, 
etc.),  etc.  The  application  of  X-rays 
has  recently  been  added  to  the  list  of 
known  causes. 

Experiments  on  guinea-pigs  which 
fully  confirm  those  of  Tellner,  showing 
that  even  short  exposures  of  the  abdo- 
men to  the  action  of  the  rays  is  Hable 
to  destroy  the  life  of  a  fetus  even 
shortly  before  term.  Alterations  were 
found  in  the  ovaries  suggesting  ster- 
ility. The  cause  of  the  fetal  death 
could  not  be  determined  macroscopi- 
cally.  Lengfellner  (Miinch.  med. 
Woch.,   Nu.  44,   1906). 

Case  of  a  tuberculous  patient  in 
whom  it  was  determined  to  interrupt 
pregnancy  with  the  hope  of  checking 
the  tuberculous  process.  Twenty-five 
applications  of  the  Rontgen  rays  were 
made,  each  lasting  from  five  to  ten 
minutes.  After  each  five  days  a  pause 
of  one   day  was  allowed  to   intervene 


JK'forc  new  applications  were  made. 
The  regions  over  the  ovaries  and  the 
thyroid  gland  were  chosen  for  the  ap- 
plications. Especial  care  was  used  to 
avoid  injury  to  the  skin.  Spontaneous 
abortion  occurred  with  free  hemor- 
rhage, which  ceased  when  the  uterine 
contents  were  expelled.  No  vaginal 
examination  was  made  during  the  case, 
so  that  the  effect  is  attributable  entirely 
to  the  Rontgen  rays.  Fraenkel  (Zen- 
tralbl.  f.  Gyn.,  Nu.  31,  1907). 

Low  or  vicious  attachment  of  the 
placenta,  degeneration  of  the  chronic 
villosities,  hydramnios  are  the  remain- 
ing main  abnormalities  which  affect 
directly  the  fetus  and  cause  its  pre- 
mature elimination  by  the  uterus. 

PROGNOSIS.— Considerable  loss 
of  blood  may  occur  in  a  case  of 
threatened  abortion,  and  yet  the  pa- 
tient, when  properly  treated,  proceeds 
to  full  term.  Cases  of  spontaneous 
abortion  unattended  by  complications 
practically  always  recover.  The  de- 
gree of  antisepsis  has  much  to  do 
with  the  result  however;  while,  for 
example,  in  Pinard's  service  where 
rigorous  asepsis  was  observed  the 
mortality  was  only  0.81  per  cent. ;  cor- 
responding cases  (which  included  fa- 
vorable and  unfavorable)  outside  his 
services  reached  27.5  per  cent. 

Six  hundred  and  ten  cases  treated  at 
the  Boston  City  Hospital  (1892-1902)  ; 
29  deaths,  or  4.75  per  cent.  They  in- 
cluded a  large  proportion  of  induced 
and  neglected  cases.  The  deaths  in- 
clude cases  with  pre-existing  typhoid 
and  pneumonia.  With  two  exceptions 
those  of  the  29  deaths  obviously  due 
to  the  miscarriage  were  caused  by 
septic  pneumonia  following  a  miscar- 
riage between  four  and  six  months. 
The  other  2  were  due  to  sepsis  after 
abortion  at  the  third  month. 

There  were  418  cases  treated  as  out- 
patients of  the  Boston  Lying-in  Kr-  - 
pital  (1892-1902).  There  were  S  acdtb?, 
or   1.2  per  cent. ;    1  case  caui<3  not  be 


164 


ABORTION    (WRIGHT). 


traced.  The  S  deaths  were  due  to  (Ij 
typhoid;  (2)  pyonephrosis;  (3)  pulmo- 
nary emboHsm;  (4  and  5)  sepsis.  Of 
the  1028  cases  but  7  were  twin  preg- 
nancies. Friedman  (Boston  Med.  and 
Surg.  Jour.,  Nov.  20,  1902). 

TREATMENT.  —  Treatment  of 
Threatened  Abortion.  —  When  the 
symptoms  of  threatened  abortion  ap- 
pear we  should  endeavor  to  stop  the 
morbid  process^  especially  when  the 
hemorrhage  is  not  copious,  the  pains 
.are  not  severe,  and  there  is  no  evi- 
dence of  the  escape  of  liquor  amnii. 
Our  chief  aim  should  be  to  keep  the 
■patient  absolutely  quiet,  by  ordering 
her  to  bed,  and  relieve  the  pains  due 
to  uterine  contractions  by  means  of 
'Opiates  in  suitable  doses.  Opium 
:seems  to  be  better  than  morphine,  even 
when  the  latter  is  given  h3^poder- 
mically.  The  tincture  of  opium,  30 
minims  (2  Gm.)  should  be  given  by 
the  mouth,  followed  by  15  minims 
(1  Gm.)  every  hour,  repeated  three  or 
four  times  if  required.  Or,  better 
still,  2  grs.  (0.13  Gm.)  of  the  aqueous 
extract  of  opium  can  be  given  as  a 
rectal  suppositor}^,  and  1  gr.  (0.065 
Gm.)  every  hour  afterward,  three  or 
four  times  if  needed.  If  morphine  be 
preferred,  ^  gr.  (0.032  Gm.)  may  be 
given  hypodermically,  and  /4  gr.' 
((0.016  Gm.)  every  hour,  therefore, 
'for  three  or  four  doses  if  required. 
An  excellent  plan  when  one  wishes 
iSpeedy  effect  from  the  opiate  is  to 
rgive  at  once  Y^  gr.  (0.032  Gm.)  mor- 
phine hypodermically,  and  15  minims 
(0.92  Gm.)  of  tincture  of  opium  by  the 
mouth  every  hour  afterward,  or  1  gr. 
(0.065  Gm.)  of  extract  of  opium  in  a 
suppository  every  hour  afterward  for 
three  or  four  doses  if  required. 

[Some  physicians  will  consider  that  such 
dosage  is  large.  Many  physicians  and  ob- 
stetricians grew  timid  about  the  use  of  opium 


because  of  the  violent  antiopium  riots  that 
broke  out  in  many  surgical  camps  about 
twenty  years  ago,  after  Lawson  Tait  told  the 
abdominal  surgeons  of  the  world  that  opium 
was  an  abomination  which  must  be  discarded 
in  their  work  forevermore.  The  pendulum 
has  turned,  however,  and  is  going  the  other 
way.     A.  H.  Wright.] 

We  ought,  of  course,  to  consider 
that  opium  should  be  given  with 
great  care.  At  the  same  time,  the 
writer  thinks  it  absurd  to  give,  for 
instance,  10  minims  (0.61  Gm.)  of 
tincture  of  opium  by  the  mouth,  three 
times  a  day,  for  the  pains  of  threatened 
abortion.  As  a  rule  such  doses  will 
have  no  good  effect,  because  they  will 
not  relieve  the  pains,  and  they  may 
have  a  bad  effect  by  causing  constipa- 
tion. Opium  does  cause  constipation, 
and  thus  interferes  with  elimination, 
but  the  writer  does  not  admit  that  it 
causes  complete  paresis  of  the  intes- 
tines. Sepsis  alone  causes  that  kind 
of  paresis. 

The  constipation  caused  by  opium 
can  be  easily  overcome  by  the  admin- 
istration of  ordinary  laxatives.  If, 
however,  the  physician  who  has  given 
opium  in  the  case  of  threatened  abor- 
tion is  afraid  to  use  mild  cathartics 
for  constipation,  he  might  order  an 
ordinary  enema. 

Some  years  ago  the  administration 
of  viburnum  prunifolium  was  sup- 
posed to  have  a  good  effect  in  cases  of 
threatened  abortion.  The  result  of 
recent  experience  does  not  indicate 
that  such  supposition  is  correct.  The 
writer  considers  it  practically  w^orth- 
less.  The  fluidextract,  %  to  1  dram 
every  three  hours,  or  10  drops  every 
hour,  with  chloral  hydrate  8  grains, 
have,  however,  been  found  effective 
in  arresting  uterine  contractions  when 
opium  could  not  be  used  or  when 
its    constipating    effects    might    prove 


ABORTION    (WRIGHT). 


165 


detrimental.  Or,  chloral  hydrate,  10 
grains,  and  potassium  bromide,  20 
grains  every  two  or  three  hours,  may 
he  preferahle,  since  the  hypnotic  tends 
to  insure  the  ahsolute  rest  and  quiet 
that  should  he  ohserved  to  ohtain  a  sat- 
isfactory result.  Codeine  is  preferred 
to  other  opiates  hy  some  obstetricians. 

Treatment  of  Inevitable  Abortion. 
— There  never  lias  been,  and  probably 
never  will  be,  a  consensus  of  opinion 
among  obstetricians  as  to  the  treat- 
ment of  abortion.  It  seems  conven- 
ient to  consider  that  there  are  three 
general  plans  :  expectant  treatment, 
treatment  by  tamponade,  forced  dila- 
tation of  the  cervix  and  curettement. 

Expectant  Plan. — The  term  expect- 
ant is  not  a  good  one  as  a  rule,  and  it 
becomes  most  unsuitable  if  it  is  mis- 
understood. 

[A  prominent  gynecologist  once  wrote : 
'Tn  my  early  experience,  cases  of  abortion 
were  treated  by  the  so-called  expectant  plan, 
a  wretched  makeshift,  and  one  that  should 
never  be  entertained.  This  plan  consists  of 
daily  visits  by  the  doctor,  who  trusts  en- 
tirely to  Dame  Nature  without  giving  her 
any  assistance.  When  fever  sets  in  it  is 
looked  upon  as  a  calamity  that  could  not  be 
avoided.  The  mother  dies  from  what  is 
called  a  bad  hemorrhage,  and  a  life  is  lost 
that  should  have  been  saved."  It  is  possible 
that  grossly  incompetent  practitioners  allow 
their  patients  thus  to  die  without  giving  any 
assistance,  but  we  have  never  seen  anything 
of  the  sort.  We  wish  to  state  positively  that 
the  above  description  of  expectant  treatment 
is  incorrect.  No  good  obstetrician  has  ever 
advocated  anything  so  absurd  as  this  sort  of 
do  nothing  treatment.     A.  H.  Weight.] 

Lusk  was  perhaps  the  most  prom- 
inent advocate  of  the  expectant  plan 
of  treatment.  He  urged  that,  when  in 
the  third  month  the  ovum  is  thrown 
off  without  the  rupture  of  the  mem- 
branes, the  hemorrhage  rarely  as- 
sumes dangerous  proportions,  and 
explained    how    the    uterine    contrac- 


tions sometimes  pressed  the  ovum 
into  the  cervix.  During  these  uterine 
contractions  the  ovum  descends  and 
tlic  upper  portion  of  the  body  of  the 
uterus  retracts.  Some  coagulation  of 
the  blood  takes  place  between  the 
ovum  and  the  retracted  uterine  walls, 
while  the  ovum  forms  a  tampon 
which  fills  the  cervix  like  a  ball  valve, 
and  thus  restrains  the  hemorrhage. 
When  there  is  no  interference,  the 
ovum,  after  being  retained  for  a  time 


Ovum,  five  weeks. 

as  described,  is  frequently  expelled 
entire,  leaving  the  uterus  in  the  best 
possible  condition  for  satisfactory  in- 
volution. In  such  cases,  and  they  are 
by  no  means  uncommon,  nature  has 
done  well.  Why  should  we  try  to 
improve  or  interfere  with  such  mag- 
nificent work? 

Removal  of  the  Uterine  Contents. 
— It  should  be  definitely  understood 
that,  while  nature  is  doing  good  work, 
we  should  watch  carefully,  and  be  ready 
to  assist  when  her  efforts  have  ceased 
to  be  efficacious.  When  the  os  and 
cervical  canal  are  sufficiently  dilated 
to  allow  the  introduction  of  the  finger 
into  the  uterine  cavity,  and  the  uterine 


166 


ABORTION    (WRIGHT). 


contents  are  not  extruded,  we  should 
interfere,  and  endeavor  to  empty  the 
uterus.  We  should  presume,  unless 
there  is  positive  proof  to  the  contrary, 
that  the  ovum  is  intact,  and  should 
not  be  broken. 

The  author  epitomizes  the  consensus 
of  opinion  in  regard  to  the  indications 
for  therapeutic  abortion.  Should  thera- 
peutic abortion  be  used  to  save  a  func- 
tion or  a  sense?  Germann  has  made  a 
thorough  study  of  the  eye  troubles  in- 
cident to  pregnancy,  and  concludes  that 
eye  complications  dangerous  to  sight, 
such  as  ulcerative  keratitis,  justify  the 
termination  of  pregnancy  with  the  ob- 
ject of  saving  as  much  sight  as  possible 
to  the  mother.  The  several  forms  of 
autointoxication  frequently  produce  eye 
diseases  which  justify  abortion.  Shall 
therapeutic  abortion  be  resorted  to  to 
save  the  life  of  the  mother  when  the 
termination  of  that  life  seems  other- 
wise inevitable?  Today,  when  the  ma- 
ternal mortality  from  Cesarean  sec- 
tion in  elective  and  uninfected  cases  is 
practically  nil,  the  physician  has  no 
right  to  sacrifice  the  fetus,  since  he  has 
this  method  of  delivery  at  command. 

In  hyperemesis,  or  incoercible  vomit- 
ing of  pregnancy,  which  occurs  once  in 
about  1000  pregnancies,  the  mortality  is 
about  50  per  cent,  under  treatment  by 
drugs  alone.  The  question  as  to  when 
abortion  should  be  induced  to  save  the 
patient's  life  has  been  satisfactorily  an- 
swered by  Norris,  who,  after  painting 
a  graphic  picture  of  the  earlier  stage 
of  this  condition,  and  describing  the 
final  stage  when  the  "typhoid"  state 
appears,  with  rapid,  feeble  pulse,  weak- 
ened heart-sounds,  fever,  restlessness, 
diminished  urine  with  albumin  and 
casts,  and  finally  delirium,  stupor,  coma 
and  death,  observes  that  "induction  of 
abortion,  to  avail,  must  not  be  delayed 
until  this  typhoid  condition  appears ;  it 
must  be  resorted  to  in  the  earlier 
stage." 

In  tuberculosis,  artificial  termination 
of  pregnancy  promises  good  results 
only  when  practised  in  the  early  months. 
Rosthorn  favors  induction  of  abortion 
in  tuberculous  processes,  whether  new 


or  old,  while  Kuttner  says  that  with- 
out interruption  of  pregnancy  the 
prognosis  in  tuberculosis  of  the  larynx 
is  exceedingly  unfavorable  for  both 
mother  and  child.  Many  authorities 
might  be  cited  to  show  that  the  inter- 
ruption of  pregnancy  had  been  followed 
by  marked  improvement  in  the  patient. 
Chronic  nephritis  is  often  an  indica- 
tion for  therapeutic  abortion,  and 
among  others  which  have  been  deemed 
justifiable  indications  may  be  mentioned 
mitral  or  aortic  lesions,  pyelitis  and 
pyelonephritis,  advanced  diabetes,  hy- 
dramnios  when  associated  with  crip- 
pled respiration  or  severe  diaphrag- 
matic pain,  leukemia,  pernicious  ane- 
mia, violent  chorea,  loss  of  sleep,  and 
continued  emaciation.  Melancholia 
may  demand  operation  if  the  condition 
is  manifestly  growing  worse,  and 
Jewett  believes  that,  in  hysterical  epi- 
lepsy, pregnancy  should  be  interrupted. 
Wilmer  Krusen  (Therap.  Gaz.,  Mar. 
15,   1910). 

The  following  course  is  recom- 
mended: Place  the  patient  across  the 
bed,  in  the  lithotomy  position,  and 
with  the  external  hand  endeavor  to 
depress  the  uterus  through  the  ab- 
dominal wall  until  the  index  finger  of 
the  other  hand  (carefully  asepticized) 
can  be  passed  through  the  os  and  up 
to  the  fundus.  An  anesthetic  is  only 
occasionally  required.  Pass  the  fin- 
ger up  on  the  lateral  wall  of  the 
uterus  until  it  is  above  the  ovum,  at 
or  near  the  opening  of  one  of  the 
Fallopian  tubes;  then  pass  it  across 
the  fundus  to  the  neighborhood  of  the 
other  Fallopian  tube,  and  sweep  down 
this  wall,  driving  the  contents  of  the 
uterus  before  it.  In  these  manipu- 
lations try  to  avoid  rupturing  the 
ovum.  If  unable  to  remove  the  ute- 
rine contents  in  the  way  described,  one 
should  try  the  following  Rotunda 
procedure  :  Take  the  finger  out  of  the 
uterus  and  place  it  under  the  fundus, 
that  is  to  say,  in  the  anterior  fornix  if 


ABORTION    (WRIGHT). 


167 


the  uterus  is  normal  in  position,  and 
in  tlie  posterior  fornix  if  the  uterus  is 
retroverted.  Sink  the  other  hand 
into  the  abdomen  and  compress  the 
body  between  the  two  hands.  The 
ovum  is  then  driven  out  of  the  uterus 
into  the  vagina  and  removed  (Jellett). 
It  is  well  to  remember  that  there  is 
a  period  between  early  and  late  abor- 
tion— say,  in  the  latter  part  of  the 
third  month — when  it  is  difficult, 
with  the  finger-tip,  to  make  out 
the  placenta,  because  it  feels  exactly 
like  the  endometrium.  It  js  possible 
under  such  circumstances  to  make 
the  mistake  of  imagining  that  the 
uterus  is  empty  while  the  thin, 
broad  placenta  is  completely  ad- 
herent. In  such  a  case  it  is  better 
to  try  to  remove  this  placenta  by 
scraping  with  the  finger-tip,  as  the 
use  of  the  metallic  curette  under  such 
circumstances  is  dangerous. 

Analysis  of  750  cases  of  abortion  of 
the  out-patient  department  of  the  Chi- 
cago Lying-in  Hospital,  and  treated  at 
their  homes.  The  routine  treatment 
adopted  in  the  276  cases  of  threatened 
hemorrhage  was  absolute  rest  in  bed, 
with  morphine  and  codeine  every  four 
hours,  with  saline  purgatives  where 
needed.  When  malposition  of  the 
uterus  was  present,  this  defect  was  cor- 
rected. The  pregnancy  was  saved  in 
72.8  per  cent,  of  the  cases.  The  in- 
evitable abortions  were  treated  by  pack- 
ing and  curetting  with  the  finger 
when  possible,  using  the  curette  only 
when  absolutely  necessary,  excepting  in 
chronic  cases.  All  the  mothers  re- 
covered. 

Summary  of  conclusions :  Absolute 
rest  was  imperative;  blood  loss  should 
always  be  prevented :  cotton  pledgets 
are  preferable  for  tampons  to  gauze, 
being  firmer;  whenever  possible  empty- 
ing of  the  uterus  should  be  done  with 
the  finger;  laminary  tents  are  difficult 
to  sterilize ;  in  acute  abortion  steel 
curettes  are  especially  liable  to  produce 


abortion ;  curetting  should  always  be 
carried  out  with  surgical  precautions ; 
curetting  is  not  indicated  when  the 
uterus  is  empty ;  ergot  is  indicated 
after  the  uterus  has  been  emptied ; 
when  the  uterus  cavity  is  septic,  the 
uterus  should  be  emptied  and  disin- 
fected; when  infection  has  spread  to 
the  peritoneum  and  uterine  adnexa  it  is 
best  to  leave  the  uterus  alone.  Stowe 
(Surg.,  Gynec.  and  Obstet.,  Jan.,  1910). 

The  Tampon. — The  vaginal  tampon 
(or  plug,  as  it  is  still  termed  by  many 
in  Great  Britain)  has  been  used  for 
various  obstetrical  purposes  for  cen- 
turies. 

[It  is  interesting  to  go  back  to  the  time 
of  Smellie  and  to  learn  his  clear  views  as 
to  its  use.  We  extract  the  following  from 
one  of  his  reports,  slightly  changed  in 
phraseology  for  the  sake  of  brevity:  "In 
the  year  1750  I  was  called  to  see  a  woman 
three  months  gone  with  child.  She  had  been 
seized  with  flooding  and  had  been  treated 
for  some  hours.  When  I  arrived  she  was 
exhausted,  faint,  and  had  slight  pains.  As 
the  danger  seemed  pressing,  I  took  the  hint 
from  Hoffmann,  and  stuffed  the  vagina  tight 
with  fine  tow  dipped  in  oxycrate  (vinegar 
and  water),  which  immediately  stopped  the 
discharge.  I  then  prescribed  an  anodyne 
draught.  She  dozed  a  little,  and  between  her 
dozing  every  now  and  then  had  slight  pains, 
though  the  flooding  did  not  return.  Toward 
morning  the  pains  grew  so  strong  that  the 
tow  was  forced  away,  together  with  the 
abortion,  about  the  size  of  a  goose-egg, 
and  some  coagulated  blood.  In  such  cases 
the  strong  pressure  of  the  plug  in  the 
vagina  seems  to  dam  up  the  internal 
flooding,  which,  by  distending  the  uterus, 
brings  on  labor  pains."  (At  this  time 
Smellie  had  been  about  thirty  years  in 
practice.)  About  one  hundred  and  twenty- 
eight  years  after  this,  i.e.,  in  1878,  McClin- 
tock,  of  Dublin,  in  commenting  on  these 
opinions  expressed  by  Smellie,  said  that 
he  readily  attributed  the  hemostatic 
effects  of  the  plug  to  its  "strong  pressure 
in  the  vagina,  damming  up  the  internal 
flooding,  which,  by  distending  the  uterus, 
brings  on  labor  pains."  McCIintock  goes 
on  to  say:  "The  occurrence  of  the  pains 
which  so  commonly  follow  the  use  of  the 


168 


ABORTION    (WRIGHT). 


plug  may,  perhaps,  be  partly  due  to  the 
cause  assigned  by  him,  but  this  increased  ex- 
pulsive action  is  merely  attributable  to  the 
influence  exerted  by  the  plug  on  the  vaginal 
surface,  the  nerves  of  which  part,  when 
irritated,  powerfully  exciting  or  bearing 
down  the  contractions  of  the  uterus."  The 
opinions  thus  expressed  were  in  ac- 
cordance with  the  practice  carried  out  in 
the  Rotunda  for  many  years  before  that 
time,  and  which  have  not  been  materially 
changed  up  to  the  present  time. 

These  old-fashioned  procedures  came  into 
disrepute    in    certain    quarters    about    thirty 


Vagina  ballema  (gauze  packing). 

j^ears  ago.  The  strenuous  gynecologist  with 
his  metallic  dilators  and  scrapers  came  to  the 
fore,  and  introduced  his  modern  methods, 
which  will  be  referred  to  again.  We  believe 
that  treatment  by  tamponade  is  the  safest 
and  best  kind  in  all  varieties  of  inevitable 
abortion,  whether  complete  or  incomplete. 
A.  H.  Wright.] 

There  are  two  kinds  of  tamponade : 
the  vaginal  and  uterovaginal. 

Vaginal  Tamponade. — In  order  to  be 
efficient  the  vaginal  tamponade  should 
be  properly  done.  Although  it  is  one 
of  the  simplest  of  obstetrical  opera- 
tions it  appears  that  in  the  majority 
of  cases  it  is  imperfectly  carried  out. 
In  the  first  place  the  vagina  cannot 
be  property  plugged  while  the  patient 


is  lying  on  her  back,  or  on  her  side. 
The  patient  must  be  put  in  the  Sims 
(semipronej  position.  The  perineum 
and  pelvic  floor  must  be  thoroughly 
retracted  by  a  Sims  speculum,  and 
the  vagina  properly  ballooned,  so  that 
its  vault,  thus  distended,  may  be  com- 
pletely filled  by  the  material  used  for 
the  packing.  It  is  only  necessary  to 
pack  tightly  the  upper  two-thirds  or 
three-fourths  of  the  vagina.  The 
mistake  commonly  made  of  packing 
tightly  the  entrance  of  the  vagina 
generally  causes  great  pain,  and  fre- 
quently retention  of  urine,  by  pres- 
sure on  the  urethra. 

The  tampon  checks  the  hemorrhage, 
dilates  the  cervix,  assists  further  sep- 
aration of  the  ovum  by  damming  back 
the  blood,  and  induces  uterine  con- 
tractions. The  writer,  like  Smellie, 
prefers  an  antiseptic  plug,  and  uses 
material  impregnated  with  5  per  cent. 
iodoform.  A  simple  sterile  plug  is 
introduced  by  some,  but  an  antiseptic 
plug  is  better.  The  former  becomes 
foul  in  about  twelve  hours,  while  the 
latter  (when  iodoform  is  used)  re- 
mains sweet  for  two  or  three  days. 
The  ordinary  iodoform  gauze  is  not 
suitable  however,  because  it  is  too 
coarse  in  texture,  that  is,  too  much  like 
a  sieve.  The  blood  easily  runs  through 
it.  Therefore,  the  writer  prefers  to 
use  a  rather  fine  cheesecloth  impreg- 
nated with  the  iodoform. 

[It  is  prepared  for  me  by  Miss  Margaret 
Lash,  as  follows :  Take  4  yards  of  cheese- 
cloth (good  qiiality)  27  inches  wide ;  tear 
(not  cut)  into  strips  4j4  inches  wide  and 
full  length ;  sterilize  these  strips,  and  then 
boil  in  sterile  water;  ring  them  as  dry  as 
possible  (having  hands  covered  by  sterile 
gloves)  and  thoroughly  saturate  them  in  the 
following  preparation :  8  ounces  of  a  1  per 
cent,  solution  of  carbolic  acid  in  sterilized 
water,  and  enough  Castile  soap  to  make 
suds;    3   drams  and  1   scruple  of  iodoform 


ABORTION    (WRIGHT), 


169 


powder ;  mix  thoroughly  in  sterile  basin 
with  sterilized  pestle  or  glass  rod.  After 
thoroughly  saturating  the  strips,  wring  as  dry 
as  possible,  and  pack  the  gauze  strips  one 
after  another  into  sterilized  glass  jars,  and 
seal  down  while  moist.  One  strip  4^^  inches 
wide  by  4  yards  long  is  ample  for  most 
vaginal  tampons.  This  happens  to  be  one- 
half  of  a  square  yard,  that  is,  3  feet  by  one 
foot  and  a  half.     A.  H.  Wright.] 

The  method  of  procedure  for  early 
abortion  is  as  follows :  Place  the  pa- 
tient in  the  Sims  position,  introduce 
a  Sims  speculum,  and  let  the  assistant 
retract  the  perineum  and  pelvic  floor 
(or  use  two  fingers  of  one  hand  for 
such  retraction,  as  recommended  by 
Schauta) ;  introduce  the  continuous 
strip  of  iodoformed  cheesecloth,  and 
firmly  pack  the  vault  of  the  vagina. 
In  doing-  this  one  should  use  not  the 
point  of  a  sound  or  forceps  with  fine 
points,  but  something  with  a  fairly 
large  surface.  My  custom  is  to  use 
the  handle  of  a  uterine  sound  when 
packing  tightly.  Continue  the  pack- 
ing until  the  upper  three-quarters  of 
the  vagina  is  filled,  and  then  allow  the 
end  of  the  strip  to  hang  out  at  the 
vulva.  If  in  a  few  hours  strong  pains 
occur,  indicating  that  regular  uterine 
contractions  are  taking  place,  take 
hold  of  the  end  of  the  strip  and  pull 
out  the  material  forming  the  plug. 
It  may  be  that  by  this  time  the  ovum 
has  been  separated  and  expelled  from 
the  uterus.  If  such  pains  do  not 
occur  remove  the  tampon  in  twenty- 
four  hours.  There  will  then  probably 
be  some  slight  dilatation  of  the  os, 
but  not  enough  perhaps  to  allow  the 
introduction  of  the  finger.  Introduce 
a  second  tampon  as  before.  The  tam- 
ponade may  be  kept  up  with  safety 
for  many  days  (a  week  or  more)  if  the 
plug  is  renewed  every  twenty-four 
hours.     It  is  unnecessary  for  the  first 


two  or  three  days  to  introduce  any  of 
the  iodoformed  strip  inside  the  uterus, 
because  the  aim  is  to  cause  uterine 
contractions  that  will  expel  the  entire 
ovum. 

If  it  is  found,  after  the  removal  of 
the  second  or  third  tampon,  that  the 
OS  and  cervical  canal  are  sufificiently 
dilated  to  allow  the  introduction  of 
the  finger,  we  may  explore  the  interior 
of  the  uterus,  as  recommended  in  con- 
nection with  the  expectant  plan,  and 
endeavor  to  remove  the  complete 
ovum.  If,  however,  a  portion  of  the 
ovum  has  come  away,  the  uterovagi- 
nal tamponade  becomes  the  proper 
procedure. 

It  may  be  well  now  to  repeat  that 
the  object  of  the  vaginal  tamponade 
is  to  cause  the  expulsion  of  the  en- 
tire ovum  during  early  abortion,  that 
is,  before  the  complete  placenta  is 
formed.  The  object  of  the  utero- 
vaginal tamponade  is  to  empty  the 
uterus  in  case  of  incomplete  abortion 
(whether  early  or  late),  and  also  in 
case  of  late  abortion,  that  is,  after  the 
complete  placenta  has  been  formed. 

Uterovaginal  Tamponade. — This  pro- 
cedure is  divided  into  two  stages :  1, 
the  packing  of  the  uterus ;  2,  the  pack- 
ing of  the  vagina.  In  packing  the 
uterus  it  is  generally  more  convenient 
to  place  the  patient  on  her  back  in  the 
lithotomy  position,  on  a  couch,  on  a 
table,  or  across  the  bed.  Introduce  a 
weight  speculum,  seize  the  anterior  lip 
of  the  uterus  with  a  volsellum  forceps, 
and  use  slight  traction.  Ordinary  iodo- 
form gauze  one-half  to  one  inch  wide 
is  now  pushed  as  far  up  as  possible 
into  the  uterine  cavity,  employing  a 
fine  curved  pair  of  uterine  forceps,  a 
uterine  gauze  packer,  or  a  uterine 
sound  to  do  so. 

In   order   to   carrv   out   the   second 


170 


ABORTION    (WRIGHT). 


stage  of  the  operation  the  patient  is 
placed  in  the  Sims  position,  and  the 
end  of  the  narrow  strip,  the  greater 
portion  of  which  has  been  passed 
into  the  uterus,  is  tied  to  the  wider 
strip  used  for  the  vaginal  tamponade. 
After  retracting  the  perineum  and 
pelvic  floor,  the  upper  three-fourths 
of  the  vagina  is  packed  tightly  in  the 
manner  previously  described. 

If  strong  uterine  contractions  occur 
the  double  plug  and  ovum  may  be 
expelled  together.  If  no  strong  ute- 
rine contractions  commence  withdraw 
tampon  in  twenty-four  hours,  and  in- 
troduce a  new  one.  This  procedure 
means,  of  course,  that  the  membranes 
will  be  punctured,  if  they  were  not 
previously  ruptured.  This  is  suitable 
for  all  cases  of  abortion  between  the 
end  of  the  third  and  the  end  of  the 
seventh  month.  In  the  seventh  month 
we  must  consider  the  possibility  of 
the  expulsion  of  a  living  child.  In 
helping  delivery  during  this  month, 
and  sometimes  in  the  fifth  or  sixth 
month,  one  may  introduce  a  gum  elas- 
tic bougie  (English  No.  12)  within  the 
uterus  or  a  medium-sized  rectal  tube 
(H.  U.  Little),  as  recommended  by 
Krause,  and  follow  with  the  vaginal 
tamponade.  However,  the  introduction 
of  the  gauze  through  the  cervical  canal 
and  into  the  lower  uterine  segment, 
with  the  vaginal  tamponade,  is  gener- 
ally quite  sufficient  to  produce  efficient 
uterine  contractions. 

The  best  method  to  adopt  to  incur 
little  risk  for  the  patient :  No  inter- 
ference is  necessary  in  ordinary  cases 
except  in  cases  of  severe  anemia  pro- 
duced by  a  profuse  hemorrhage  or  by 
long-continued  slighter  bleeding,  when 
portions  of  the  ovum  are  retained,  and 
in  cases  which  have  become  septic.  The 
most  rational  method  of  arresting 
hemorrhage  is  to  remove  the  ovum  com- 


pletely. If  this  has  left  the  body  of 
the  uterus,  and  is  retained  partially  or 
totally  in  the  cervix  or  vagina,  a  spec- 
ulum should  be  introduced,  and,  if  the 
finger  cannot  easily  complete  the  re- 
moval, ovum  forceps  may  be  used. 
When  the  ovum  is  still  in  the  body  of 
the  uterus,  one  or  two  fingers  should  be 
introduced,  and — while  counterpressure 
is  exercised  by  the  other  hand  from 
the  abdominal  wall — the  sac  separated 
completely  from  the  uterine  wall.  Once 
it  has  been  separated,  it  can  usually 
be  removed  by  combined  action  of  the 
internal  finger  and  expression  from 
without.  The  whole  process  can  be 
made  more  easy  if  one  seizes  the  an- 
terior lip  of  the  cervix  with  volsellum 
forceps  (double-toothed),  and  admin- 
isters an  anesthetic.  The  operator 
must  not  be  disturbed  by  the  hemor- 
rhage, but  must  rely  on  the  fact  that 
this  will  cease  on"  completion  of  the 
abortion.  If  the  cervix  is  not  permeable 
for  the  finger,  thorough  plugging  of  the 
uterus,  cervix,  and  vagina  with  sterile 
iodoform  gauze  is  then  indicated.  The 
cervix  is  brought  into  view  with  a  Sims 
speculum,  the  direction  of  its  canal  is 
ascertained  by  means  of  a  uterine  cathe- 
ter or  sound,  and  the  size  of  the  uterus 
by  bimanual  examination,  and  not  by 
the  sound.  The  vagina  is  to  be  thor- 
oughly irrigated,  cleansed,  and  dried, 
and  then  the  strips  of  gauze  introduced 
with  smooth  ovum  forceps.  All  one's 
efforts  should  be  directed  toward  keep- 
ing the  ovum  intact.  At  times  it  may 
be  necessary  to  substitute  a  sound  for 
the  forceps  in  packing  the  uterus.  If 
the  ovum  is  not  cast  oixt  after  twenty- 
four  hours,  the  plugging  is  to  be  re- 
moved, the  passage  again  thoroughly 
disinfected,  and  a  second  packing  un- 
dertaken. Sellheim  (Miinch.  med. 
Woch.,  March  11,   1902). 

The  treatment  of  abortion  is  consid- 
ered by  the  writer  under  three  heads: 
(1)  imminent  abortion  may  be  pre- 
vented by  absolute  rest  in  bed  and  the 
use  of  drugs  like  codeine  and  vibur- 
num prunifolium;  (2)  progressing 
abortion,  and  (3)  incomplete  abortion 
may  be  assisted  to  a  spontaneous  ter- 
mination  by   a   hot   vaginal   antiseptic 


ABORTION    (WRIGHT). 


171 


douche    and    vaginal    gauze    packing. 

An  oxytocic  should  be  administered  in- 
ternally. If  the  result  is  not  satisfactory 
after  twenty-four  hours,  the  partially 
dilated  cervical  canal  should  be  packed 
with  gauze  and  the  vagina  below  tightly 
filled  with  the  same  material.  Uterine 
contraction  will  thus  be  usually  incited 
and  everything  expelled.  If  too  much 
bleeding  is  going  on,  the  uterus  may  be 
emptied  with  the  finger  or  placenta 
forceps,  and  ergot  administered,  two  or 
three  doses  usually  sufficing.  H.  J. 
Boldt  (Jour.  Amer.  Med.  Assoc,  Mar. 
17,  1906). 

Table  containing  the  kernel  of  the 
operative  indications.  If  conscien- 
tiously followed,  it  will,  the  writer 
believes,  lead  to  considerable  improve- 
ment in  the  practitioner's  treatment  of 
abortion  and  miscarriage. 


tion  is  injected.  Of  course,  careful 
asepsis  must  be  maintained.  In  giving 
the  injection  it  is  best  to  use  a  Sims 
speculum.  If  results  are  not  prompt, 
the  injection  may  be  repeated  in  a  few 
minutes.  Crasser  (Centralbl.  f.  Gynak., 
Nu.  25,  1909). 

Conclusions  based  on  the  results  in 
2000  cases  of  miscarriage:  1.  Spontane- 
ous emptying  of  the  uterus  takes  place 
in  but  about  13.2  per  cent,  of  all  miscar- 
riages. 2.  The  likelihood  of  a  miscar- 
riage to  complete  itself  increases  with 
the  duration  of  pregnancy.  3.  When  it 
becom.es  necessary  to  use  artificial 
means  to  complete  the  miscarriage,  the 
finger  followed  by  the  curette  in  later 
miscarriages,  and  the  curette  alone 
in  the  earlier  months  of  pregnancy,  has 
given  uniformly  satisfactory  results.  4. 
Experience   has   shown  that   where  the 


Outline   of   Treatment   in.   Abortion    and  Miscarriage. 


Ovum   re- 
tained. 


Ovisac  or 
placenta 
retained. 


Placental 
pieces  or 
decidua 
retained. 


FiEST  Six  Weeks  of  Preg- 
nancy. 


Cervix   closed. 


Cervical    and 
vaginal  tam- 
ponade. 


Uterine    tam- 
ponade. 


Dull     curette. 


Cervix  open. 


Removal    with 
one    finger. 


Removal    with, 
o-vum    for- 
ceps   under 
guidance     of 
finger. 


Dull     curette. 


Seventh  to  the  Thirteenth 
Week. 


Cervix  closed.     Cervix  open. 


Cervical   and     Removal    with 
vaginal  tam-     one  finger, 
ponade. 


Uterine    tam-  Removal    with 
ponade.  one    finger 


Dull    curette. 


Dull    curette 
under    guid- 
ance  of 
finger. 


Fourth  to   the  Sixth 
Month. 


Cervix  closed.     Cervix  open. 


Tamponade  or  Removal  with 
dilate  with  two  fingers, 
small  Voor- 
hees    bag. 


Tamponade  or  Removal  with 
dilate  with  |  one  or  two 
finger.  fingers. 


Curette    care-  Removal    with 


fully  or  di- 
late to  admit 
finger. 


one  finger. 


F.  J.  Taussig-  (Surg;.,  Gynec.  and  Obstet..  May,  1909). 


For  several  years  the  writer  has  been 
in  the  habit  of  injecting  adrenalin  into 
the  uterine  cervix  in  cases  in  which 
there  was  bleeding  after  abortion  with 
retention  of  the  placenta.  It  not  only 
controls  the  bleeding,  but  aids  in  the 
expulsion  of  the  placenta.  He  believes 
that  the  method  is  safe  and  efficacious, 
and  prompt  in  its  influence.  Two  to 
three  drops  of  adrenalin  solution  mixed 
with   1    c.c.   of  physiological   salt   solu- 


cervix  is  extremely  rigid  it  is  better  to 
introduce  the  curette  and  break  up  the 
fetus  and  placenta  and  remove  them 
piecemeal  than  to  attempt  to  dilate  the 
cervix  sufficiently  to  introduce  the  fin- 
ger. 5.  Packing  the  vagina  and  lower 
segment  of  the  uterus  is  an  unsatisfac- 
tory and  often  unsuccessful  method  of 
emptying  the  uterus.  No  success  what- 
ever was  obtained  in  treating  incom- 
plete miscarriages  in  this  way.    6.  Pack- 


172 


ASORTION    (WRIGHT). 


ing  is,  however,  of  great  value  in  two 
classes  of  cases:  First,  in  exsanguin- 
ated patients  to  stop  the  hemorrhage 
and  give  the  woman  a  chance  to  re- 
cover somewhat  from  the  loss  of 
blood  before  emptying  the  uterus. 
Second,  when  the  cervix  is  very 
rigid,  a  tight  cervical  pack  for 
twenty-four  hours  will  soften  it  so 
that  dilatation  may  be  attempted  with 
safety.  7.  The  results  of  artificial 
methods  are  as  good  as,  but  not 
better  than,  where  nature  has  suc- 
ceeded in  emptying  the  uterus.  8.  Arti- 
ficial methods  are  necessary  in  a  major- 
ity of  cases,  however,  simply  because 
nature  has  failed.  9.  In  infected  cases 
the  essential  thing  is  to  get  rid  of  the 
infectious  material  by  emptying  the 
uterus,  the  particular  method  employed 
making  little  difference.  10.  The  later 
in  pregnancy  miscarriage  occurs,  the 
smaller  the  liability  to  become  infected, 
but  the  greater  the  likelihood  of  de- 
veloping grave  septic  complications  if 
infection  does  take  place.  11.  The 
mortality  is  practically  the  same  at  all 
periods  of  pregnancy.  12.  Induced 
abortions  have  a  greater  mortality  than 
accidental.  The  mortality  of  patients 
admitted  to  the  hospital  aft^r  criminal 
abortions  was  10  per  cent.  E.  B.  Young 
and  J.  T.  Williams  (Boston  Med.  and 
Surg.  Jour.,  June  22,  1911). 

Treatment  o£  Incomplete  Abortion. 

— Some  authors  state  that  the  uterus 
may  be  emptied  at  once,  the  cervical 
canal  being  dilated  and  the  finger  or 
curette  or  both  being  used.  Occasion- 
ally the  finger  may  be  used  v^ith  ad- 
vantage when  the  cervical  canal  is 
well  dilated,  but  we  do  not  advise  the 
use  of  the  curette.  Others  hold  that 
we  should  not  interfere  until  there  is 
decomposition  of  the  ovum  or  danger- 
ous hemorrhage.  We  do  not  approve 
of  this  kind  of  expectant  treatment. 

Without  discussing  these  or  other 
methods  of  treatment  we  recommend 
the  uterovaginal  iodoform  tamponade 
for  all  kinds  of  incomplete  abortion, 


whether  occurring  before  Or  after  the 
formation  of  the  placenta.  In  these 
cases  there  is  nearly  always  some 
dilatation  of  the  cervical  canal,  gen- 
erally enough  to  allow  the  introduc- 
tion within  the  uterus  of  a  narrow 
strip  of  iodoform  gauze.  If  the  canal 
which  was  once  slightly  dilated  has 
again  become  so  contracted  that  no 
gauze  can  be  passed  through  it  we 
may  do  the  vaginal  tamponade  as  be- 
fore directed,  and  thereby  cause  suffi- 
cient dilatation  for  our  purposes.  If 
we  use  the  iodoform  gauze  or  cheese- 
icloth  instead  of  ordinary  sterile  gauze, 
we  do  not  fear  the  danger  of  decom- 
position which  is  said  by  some  to 
occur  in  the  uterine  cavity  about  the 
vaginal  plug.  If,  however,  one  fears 
such  an  occurrence  he  should  remove 
the  vaginal  plug  in  ten  or  twelve 
hours,  instead  of  waiting  twenty-four 
hours,  as  we  have  generally  recom- 
mended. The  uterovaginal  tamponade 
may  be  repeated  several  days  if  con- 
sidered necessary. 

If  after  waiting  one  or  two  weeks 
the  accoucheur  has  reason  to  fear  that 
some  portions  of  the  egg  have  been 
retained,  and  there  are  no  signs  of 
sepsis,  he  may  use  a  dull  curette  with 
great  care. 

Sepsis  with  incomplete  abortion  is 
a  very  serious  complication.  The 
curette,  whether  dull  or  sharp,  should 
never  be  used  when  there  is  septic 
endometritis  or  even  saprophytic  in- 
fection. The  finger  may  be  used  very 
gently  to  remove  debris  when  the 
cervical  canal  is  sufficiently  dilated. 
Then  use  an  intrauterine  douche  of 
warm  salt  solution.  After  the  douche 
is  used  introduce  iodoform  gauze  (the 
coarser,  the  better)  into  the  uterus, 
and  place  a  certain  amount  in  the 
vagina  without  packing  tightly.     Leave 


ABORTION    (WRIGHT). 


173 


this  in  six  hours,  and  then  remove. 
After  this  removal  keep  the  patient  as 
much  as  possible  in  Fowler's  position, 
that  is,  a  half-sitting  position,  to  facili- 
tate drainage.  Apart  from  such  local 
treatment  carry  out  the  usual  line  of 
treatment  recommended  for  puerperal 
infection. 

Method  of  dealing  with  an  infection 
after  an  abortion.  The  cavity  of  the 
uterus  is  first  cleaned  out  to  prevent 
the  continued  absorption  of  toxins  from 
any  infectious  material  which  may  be 
present,  and  thus,  at  least,  limit  the  in- 
tensity of  the  process.  For  this  the  fin- 
ger alone  is  employed,  or  combined  with 
the  curette.  The  cavity  of  the  uterus 
is  washed  out  with  hot  saline  and  2 
ounces  of  peroxide  of  hydrogen;  it  is 
then  cleansed  with  saline  solution  and 
sponged  dry.  After  this  2  or  3  drams 
of  iodoform  powder  are  placed  in  the 
uterine  cavity,  which  is  then  packed 
with  sterile  gauze.  Now  the  cul-de-sac 
is  freely  opened,  and,  after  evacuating 
any  fluid  which  may  be  present,  it  is 
irrigated  with  hot  saline,  followed  by  2 
ounces  of  peroxide  of  hydrogen.  This 
in  turn  is  washed  out  and  the  cavity 
wiped  dry.  Last,  2  or  3  drams  of  ster- 
ilized iodoform  powder  are  dusted  into 
the  cul-de-sac,  after  which  it  is  packed 
tightly  with  strips  of  sterile  gauze. 

By  this  procedure  the  author  believes 
that  two  advantages  are  obtained:  (1) 
by  evacuating  the  fluid  from  the  cul-de- 
sac  further  absorption  is  prevented; 
(2)  the  ovaries  and  Fallopian  tubes  are 
saved  by  preventing  adhesions  which 
would  almost  invariably  form  as  a  re- 
sult of  the  organization  of  the  exudate. 
Personal  experience  has  shown  that  the 
secretions  from  the  uterine  cavity  are 
almost  always  sterile,  while  organisms 
are  invariably  found  in  the  exudate  in 
the  cul-de-sac.  Hunter  Robb  (Amer. 
Gyn.,  June,  1903). 

Continuous  or  frequent  irrigations 
urged  to  prevent  absorption  from  the 
lochia  and  thereby  the  production  of 
the  toxemic  element  of  puerperal  sep- 
sis. Weil  (N.  Y.  Med.  Jour.,  May  18, 
1911). 
When    a    septic    abortion    is    recog- 


nized it  must  first  be  determined  that 
the  infection  has  not  extended  beyond 
the  uterus  before  active  treatment  is  in- 
stituted. When  the  diagnosis  of  septic 
abortion  has  been  confirmed  and  the 
disease  is  confined  to  the  uterus  the 
next  procedure  of  the  physician  should 
be  determined  by  the  bacteriological  ex- 
amination, except  when  there  is  con- 
siderable hemorrhage ;  in  these  cases 
immediate  curettage  is  indicated.  If 
the  bacteriological  examination  reveals 
the  presence  of  streptococci,  staphy- 
lococci, bacteria  coli,  or  the  ordinary 
saprophytes  curettage  should  be  prac- 
tised and  no  serious  results  are  to  be 
expected.  But  if  the  examination  re- 
veals the  presence  of  hemolytic  strep- 
tococci, especially  if  in  pure  cultures 
and  with  distinct  hemolysis,  the  writer 
advises  against  any  local  intervention, 
as  the  danger  involved  is  very  great. 
The  treatment  should  be  general,  to 
increase  the  power  of  resistance  of  the 
organism  in  the  expectation  that  the 
infection  will  be  overcome  by  local  re- 
action. Ergotin  treatment  is  indicated 
to  limit  absorption  through  a  firm  con- 
traction of  the  uterine  wall  and  at  the 
same  time  favor  expulsion  of  the  re- 
mains of  the  fetus.  Winter  (Med. 
Klinik,  April  16,  1911). 

Winter's  advice  not  to  interfere  in 
septic  abortion,  except  in  the  case  of 
hemorrhage,  until  several  weeks  have 
passed,  all  symptoms  of  infection  hav- 
ing disappeared,  and  the  uterus  is  not 
completely  empty,  is  only  valid  in  one 
respect,  viz.,  the  liability  of  multiple 
infections  from  curetting,  a  sharp  rise 
in  temperature  nearly  always  following 
the  operation.  Many  cases  would  ter- 
minate fatally,  however,  were  it  not  for 
timely  curetting.  Many  conservative 
gynecologists  confine  themselves  to  for- 
ceps, sponges,  or  the  finger  and  never 
use  the  curette.  De  Bovis  (Semaine 
med.,  July  26,   1911). 

Curettage  and  Emptying  the  Uterus 
at  a  Single  Sitting. — This  operation 
may  be  occasionally  justifiable  when 
there  appears  to  be  urgent  need 
of  rapid  emptying  of  the  uterus. 
Whether   this   be   true   or   not    it   is 


174 


ABORTION    (WRIGHT). 


recognized  as  a  legitimate  operation 
by  some  of  the  best  obstetricians  and 
gynecologists  in  the  world.  A  brief 
description  of  the  procedure  is  there- 
fore given.  Anesthetize  the  patient, 
place  her  in  the  lithotomy  position 
"across  bed,"  preferably  on  a  Kelly  pad. 
Prepare  external  parts  and  vagina  as 
for  vaginal  hysterectomy,  using  espe- 
cially green  soap  and  hot  water,  and  a 
hot  solution  of  lysol  or  other  germi- 
cide. Introduce  a  weight  speculum, 
secure  the  anterior  lip  of  the  cervix 
with  volsellum  forceps,  introduce  a 
branched  steel  instrument  into  the 
cervical  canal,  and  dilate ;  then  intro- 
duce a  curette  into  the  interior  of  the 
uterus  and  scrape  out  its  contents. 
Some  operators  then  wash  out  the 
interior  of  the  uterus  with  an  antisep- 
tic solution,  while  others  use  the 
uterine  iodoform  tamponade. 

Two  hundred  and  seven  cases  per- 
sonally treated  with  curette.  Sequelae 
were  met  with  in  34.4  per  cent.,  com- 
pared with  92.4  in  those  in  which  it 
was  not  employed.  In  the  former,  the 
menses  were  regularly  re-established 
in  60  per  cent.,  pregnancy  to  term 
supervened  in  53  per  cent.,  abortion  re- 
curred in  only  13  per  cent.,  and  sterility 
prevailed  in  32.3  per  cent.  When  the 
curette  was  not  used  and  fingers  were, 
regular  menstruation  in  39.4  per  cent., 
pregnancy  to  term  also  in  39.4,  repeated 
abortion  in  47.3,  and  sterility  in  25.1. 
The  cases  were  all  treated  upon  the 
same  general  principles,  and  the  curette 
was  only  employed  in  the  presence  of 
the  strongest  indications.  Schaeffer 
(Deut.  Prax.,  Nos.  1-3  and  5-8,  1901). 

An  incomplete  abortion  may  be  rec- 
ognized by  the  bloody  charge,  sepsis  or 
failure  of  involution  as  instanced  by  the 
soft,. boggy  uterus,  the  patulous  cervix, 
and  the  detection  during  the  examina- 
tion of  fragments  of  the  ovum.  On  the 
other  hand,  if  the  abortion  has  been 
wholly  completed,  that  is,  if  the  entire 
uterine    contents,   including  the   hyper- 


trophied  decidua,  have  been  completely 
expelled,  the  uterus  is  firmly  contracted 
and  the  os  is  closed.  The  management 
of  incomplete  abortions  is  purely  sur- 
gical, for  drugs  have  little  or  no  effect 
on  the  expulsion  of  retained  portions 
of  the  ovum.  Hemorrhage,  sepsis  and 
adrenal  inflammations,  with  their  com- 
plicating sequelae,  can  alone  be  con- 
trolled and  avoided  by  prompt  aseptic 
emptying  of  the  uterus.  Here  again, 
as  in  the  treatment  of  inevitable  abor- 
tions, the  strictest  asepsis  and  the  most 
delicate  skill  are  necessary  to  evacuate 
the  uterus  without  traumatizing  the  pas- 
sages. No  expectant  plan  of  treatment 
has  given  any  satisfaction ;  the  situa- 
tion should  be  explained  to  the  family, 
as  well  as  the  dangers  from  the  possi- 
ble sequelae  and  the  necessary  opera- 
tion made.  J.  O.  Polak  (Long  Island 
Med.  Jour.,  June,  1907). 

Treatment  of  Criminal  Abortion. — 

In  the  majority  of  cases  of  criminal 
abortion  we  have  incomplete  abor- 
tion with  sepsis.  We  have  to  con- 
sider at  the  same  time  that  some 
injury  may  have  been  done  by  the 
operator  in  his  manipulations.  One 
of  the  most  common  of  such  injuries 
is  puncture  of  the  uterine  wall.  The 
possibility  of  such  injury  should  make 
us  doubly  careful  in  our  methods  of 
treatment. 

In  performing  an  autopsy  upon  a 
woman  who  is  supposed  to  have  at- 
tempted abortion  search  should  be  made 
for  the  embryo  or  pieces  of  it,  or  for 
the  placenta.  If  the  uterus  is  empty, 
the  thickness  of  its  walls  must  be 
measured,  and  the  insertion  of  the 
placenta  sought,  as  this  can  be  recog- 
nized up  to  the  tenth  day  after  the  ex- 
pulsion of  the  embryo.  This  is  possi- 
ble even  later,  if  the  uterus  is  kept  in 
90  per  cent,  alcohol.  The  examination 
of  the  ovaries  is  of  only  relative  im- 
portance, as  no  positive  signs  exist 
there.  Stains  of  meconium,  if  found, 
will  prove  the  abortion.  If  an  instru- 
ment has  been  used  to  cause  abortion, 
traces  of  the   damage   done  by  it  will 


ABORTION    (WRIGHT). 


175 


be  seen.  This  is  cspeciallj'  true  when 
the  nterus  has  been  perforated,  llron- 
ardel  (Jour,  des  Pratieiens,  Jan.  13, 
190n. 

Six  hinidred  and  ninety-eight  cases  of 
abortion  witnessed,  supposed  to  be  spon- 
taneous. Four  of  the  women  died,  that 
is,  0.57  per  cent.  During  the  same 
period  44  cases  of  criminal  abortion 
were  treated;  tlie  niortalit}'  was  56.8 
per  cent.,  that  is,  only  19  women  re- 
covered. In  the  presence  of  a  complete 
or  incomplete  abortion,  due  unmistak- 
ably to  mechanical  measures,  or  even 
when  such  abortive  measures  are  sus- 
pected, and  in  absence  of  any  compli- 
cation, early  evacuation  of  the  uterus 
is  required.  If  septic  accidents  have 
already  developed,  evacuation  is  still 
more  urgent,  and  general  measures  are 
also  indicated.  Ma3'grier  (L'Obste- 
trique,  July  4,  1902). 

When  the  patient  is  kept  in  an  aseptic 
condition,  that  is,  without  local  exam- 
ination or  other  maneuvers,  and  hot 
douches  are  given  only  in  numbers 
sufficient  to  combat  alarming  hemor- 
rhage, the  temperature  keeps  within 
normal  range.  Careful  watching  may 
show  a  slight  rise ;  at  the  same  time 
slight  hemorrhage  may  recur  or  a  very 
slight  fetid  odor  may  be  noticed  in  the 
secretions-.  These  signs  show  that  the 
fetus  is  dead,  that  the  placenta  has 
become  a  foreign  body,  and  that  the 
uterus  is  trying  to  expel  it.  This  is  the 
time  for  curetting  if  spontaneous  ex- 
pulsion does  not  rapidly  follow.  At 
this  time  the  operation  is  easy  and  with- 
out danger.  In  case  of  primary  uterine 
infection  with  temperature  above  38°  C, 
the  curette  should  be  used  at  once. 
It  is  easy  to  order  injections  at  45°  or 
48°  C.  (113°  or  118°  F.),  but  they  are 
generally  given  tepid  and  thus  only 
aggravate  the  tendency  to  hemorrhage. 
Each  douche  should  be  preceded  by  a 
careful  toilet  of  the  external  genitals. 
In  curetting  wait  until  the  uterus  con- 
tracts, curetting  gently  during  the 
period  of  relaxation  after  a  contraction, 
and  using  the  largest  curette  possible. 
Curette  at  the  moment  when  the 
placenta  is  almost  entirely  separated 
and  the  uterus  offers  a  thick  and  re^ 


sisting  wall.  Perforation  may  well  be 
feared  when  there  is  infection  in  the 
uterus,  for  then  one's  hand  is  forced 
and  the  curetting  may  be  done  while 
the  placenta  is  still  too  firmly  adherent. 
De  Bovis  (Semaine  med.,  No.  43,  1910). 

Treatment  of  Patient  with  "Abort- 
ing Habit." — Wlien  we  have  treated 
a  certain  patient  for  two  or  three 
threatened  abortions  which  have  be- 
come inevitable,  the  presence  of  syph- 
iHs  should  be  carefully  inquired  into. 
If  there  is  a  syphilitic  taint,  or  even  a 
suspicion  of  it,  both  patient  and  hus- 
band should  be  placed  under  constitu- 
tional treatment.  Malformations,  dis- 
placements and  other  abnormalities 
of  the  uterus,  and  other  conditions 
which  act  as  direct  causes  of  abortion 
may,  of  course,  prevail  in  these  cases, 
and  should  be  carefully  soug-ht  after. 

Two  cases  in  which  the  writer  was 
able  to  correct  a  tendency  to  habitual 
abortion  by  the  systematic  introduction 
into  the  uterus  of  a  suction  cannula. 
It  not  only  induces  hyperemia  in  the 
organ,  but  stimulates  it  to  muscular 
contractions,  this  exercise  aiding  in  re- 
storing normal  conditions.  In  the  first 
case  he  applied  the  cannula  for  half  an 
hour  at  a  time,  at  twenty  sittings  in 
the  course  of  seven  weeks ;  in  the  sec- 
ond case  the  cannula  was  left  for  ten 
hours  at  a  time,  the  procedure  being 
repeated  eight  times  in  the  course  of 
one  month.  Both  women  have  since 
borne  healthy  children,  although  there 
was  a  history  of  five  and  three  abor- 
tions, respectively;  the  patients  were 
27  and  23  years  old.  Turan  (Deut. 
med.  Woch.,  May  5,   1910). 

Apart  from  such  considerations, 
rest  and  quiet  are  the  important  ele- 
ments in  the  treatment  of  such  cases. 
The  patient  should  be  kept  in  bed  or 
on  a  lounge  from  two  days  before  the 
time  of  menstruation  until  three  days 
after  it  ceases.  In  addition,  if  the 
patient    is    restless    or    sleepless,    she 


176 


ABORTION    (WRIGHT). 


should  receive  enough  opium  or  other 
hypnotic,  such  as  veronal,  to  make  her 
sleep  at  least  fairly  well  every  night. 
During  intervals  she  should  have  a 
moderate  amount  of  exercise  in  the 
open  air,  and  suitable  tonics.  Strong 
purgatives,  vaginal  douching,  sports, 
and  all  kinds  of  fatiguing  work  should 
be  carefully  avoided.  In  case  of  re- 
troversion or  retroflexion,  the  displace- 
ment should  be  corrected,  introducing, 
if  necessary,  a  suitable  pessary,  and 
leaving  it  until  about  the  end  of  the 
fourth  month. 

ABERRANT  FORMS.— The  rec- 
ognition of  such  conditions  obviously 
is  of  great  diagnostic  importance. 

Missed  Abortion. — The  retention  of 
the  ovum  within  the  uterus  after  its 
death  is  thus  termed.  The  death  of 
the  ovum  may  occur  before  or  after 
the  formation  of  the  placenta,  but  it 
is  most  apt  to  happen  in  the  third 
month.  This  is  probably  due  to  the 
fact  that  at  that  time  the  egg  is  to 
some  extent  loosened  on  account  of 
the  atrophy  of  a  large  portion  of  the 
chorionic  villi.  The  death  of  the  fe- 
tus frequently  occurs,  however,  in  the 
fourth,  fifth,  sixth  or  seventh  month, 
and  in  a  certain  proportion  of  these 
cases  the  abortions  are  "missed." 

The  term  missed  abortion  is  inap- 
propriate, as  it  is  used  as  a  synonym 
for  delayed  abortion.  The  period  from 
the  death  of  the  fetus  until  it  is  ex- 
truded is  unusually  prolonged,  and  it 
undergoes  important  changes  —  those 
due  to-  a  cessation  of  vitality.  This 
period  may  be  devoid  of  symptoms,  and 
as  a  rule  the  embryo  has  been  dead 
some  weeks  or  months  before  the 
patient  comes  under  observation.  J. 
Oliver  (N.  Y.  Med.  Jour.,  Dec.  3, 
1904). 

It  is  a  singular  fact,  in  connection 
with  a  case  of  missed  abortion,  that 


the  dead  ovum  frequently  or  generally 
remains  in  the  uterus  quiescent  until 
term.  In  some  cases  the  dead  ovum 
still  remains  quiescent  for  an  indefinite 
time,  even  after  term,.  Although  we 
cannot  speak  very  definitely,  we  know 
that  the  dead  ovum  may  remain  in  the 
uterus  without  any  change  in  struc- 
ture for  one,  two  or  more  years.  At 
least  such  appears  to  be  the  opinion  of 
the  majority  of  obstetricians  at  the 
present  time. 

Case  in  which  a  dead  fetus  had  been 
carried  in  utero  for  probably  six  and  a 
half  months  without  causing  physical 
disturbance.  One  month  after  the  last 
menstrual  period,  she  began  to  show 
symptoms  of  pregnancy,  morning  sick- 
ness, enlargement  of  the  breasts,  etc. 
At  about  the  fifth  month  from  the  time 
her  menses  ceased  she  commenced  to 
look  for  signs  of  "life,"  which  did  not 
appear.  Ascribing  her  symptoms  to 
early  menopause,  she  ceased  to  give 
herself  a  thought  about  her  condition, 
gained  in  weight,  and  felt  quite  com- 
fortable. On  March  12,  1911,  at  about 
3  A.M.,  she  commenced  to  have  cramp- 
like pains  and  expelled  a  sac  which  on 
examination  proved  to  be  a  fetus  of 
about  three  and  a  half  months,  with 
cord  and  placenta  connected.  Micro- 
scopically the  placenta  showed  a  fatty 
degeneration  of  the  entire  mass.  The 
fetus  was  of  a  dark  and  brownish 
black.  Ohlbaum  (Med.  Record,  Aug. 
26,  1911). 

[This  fact  is  sometimes  of  great  impor- 
tance from  a  medicolegal  standpoint.  The 
case  of  Kitson  vs.  Playfair,  which  was  tried 
in  England  about  fourteen  years  ago,  created 
intense  interest.  Dr.  Playfair,  the  distin- 
guished teacher  and  writer  on  obstetrics  and 
gynecology,  while  treating  in  an  ordinary 
professional  way  Mrs.  Kitson,  the  wife  of 
Mrs.  Playfair's  brother,  emptied  the  uterus, 
and  found  something  like  fresh  placenta. 
Examination  under  the  microscope  confirmed 
his  suspicion,  and  he  expressed  the  opinion 
that  there  had  been  a  recent  incomplete  abor- 
tion. As  Mrs.  Kitson  had  not  seen  her  hus- 
band for  over  a  year  (he  being  in  India  and 


ABORTION    (WRIGHT). 


177 


she  in  Lingland)  this  meant  a  charge  of  im- 
morality. Dr.  Playfair  informed  his  wife, 
and  Mrs.  Kitson  was  dismissed  in  disgrace 
from  her  ordinary  circle  of  relatives  and 
acquaintances.  The  husband  in  consequence 
entered  action  against  Dr.  Playfair.  At  the 
trial  several  leading  obstetricians  agreed 
with  Playfair,  while  others  took  the  opposite 
view,  and  said  the  substance  removed  might 
have  been  the  result  of  a  conception  at 
least  eighteen  months  before.  The  case  was 
decided  in  favor  of  Mrs.  Kitson,  and  Play- 
fair was  compelled  to  pay  a  large  amount  for 
"damages."  The  suit  cost  him  altogether 
over  $50,000.  We  may  add  that  many  at  the 
time  of  the  trial  thought  that,  even  if  Dr. 
Playfair  had  been  correct  in  his  contention, 
he  was  not  justified  in  revealing  a  profes- 
sional secret.     A.  H.  Wright.] 

Mole. — When  the  dead  ovum  or  a 
portion  of  it  is  retained  in  the  uterus 
it  is  called  by  many  a  mole.  When 
there  has  been  extravasation  of  blood 
between  the  layers  of  the  membranes 
or  into  the  substance  of  the  decidua, 
coagulation  takes  place  and  the  mass 
with  its  clot  or  clots  is  called  a  "blood 
mole."  When  there  has  been  repeated 
extravasation  of  blood  within  the 
ovum  the  blood-strata  undergo  partial 
organization  and  the  mass  is  called  a 
"flesh  mole."  This  flesh  mole  retains 
to  some  extent  its  attachment  to  the 
uterine  wall,  and  in  some  cases  after 
partial  detachment  may  form  new  at- 
tachments. Under  such  circumstances 
the  detention  of  the  mass  within  the 
uterus  may  be  much  prolonged,  as 
before  mentioned. 

The  fleshy  mole  is  undoubtedly  a 
form  of  the  process  known  as  "abor- 
tion," but  the  obstetrician  should  re- 
member that  the  pathological  changes 
which  produce  it  may  occur  at  very 
different  stages  of  pregnancy.  The 
precise  time  at  which  the  arrest  of  nor- 
mal pregnancy  occurs  cannot  always  be 
determined  by  examination  of  a  fleshy 
mole.  Neumann  (Monats.  f.  Geburt. 
H.  Gyn.,  Feb.,  1897). 

In  tuberose  fleshy  mole,   abortion  is 


produced  in  the  following  manner : 
There  is  an  undue  blocking  of  the  se- 
rotinal  sinuses  in  the  large-celled  layer, 
leading  to  a  slow  engorgement  of  the 
intervillous  circulation.  This  will  bulge 
out  the  choriobasal  septa,  and,  as  these 
tack  down  the  chorion  at  definite  points, 
the  amnion  and  chorion  will  bulge  up 
between.  This  produces  the  tuberose 
swellings.  The  embryo  dies  as  the  re- 
sult of  this  interference  with  the  cir- 
culation, and  its  death  is  "secondary." 
The  placenta  becomes  a  thrombosed 
mass  and  is  retained  a  certain  time 
before  expulsion.  The  primary  link  in 
the  chain  of  events  is  the  excessive 
clotting  in  the  serotinal  sinuses  from 
a  cause  as  yet  unknown.  D.  Berry  Hart 
(Jour,  of  Obstet.  and  Gynec.  Brit.  Em- 
pire, May,  1902). 

Treatment  of  Uterine  Flesh  Mole. — 
There  is  far  from  a  consensus  of 
opinion  as  to  the  treatment  of  such  a 
mole.  Some  say  leave  it  alone  if 
there  are  not  disturbing  symptoms ; 
others  say  -empty  the  uterus  at  once 
when  a  diagnosis  is  made.  It  hap- 
pens that  a  diagnosis  is  frequently 
difficult  or  impossible,  and  it  also  hap- 
pens that  in  the  majority  of  cases  the 
mole  is  expelled  from  the  uterus  with- 
in a  reasonable  time.  The  general 
practitioner  will  be  on  the  safe  side 
not  to  interfere  unless  serious  symp- 
toms arise.  If  very  serious  symptoms 
do  appear  he  should  at  once  do 
the  uterovaginal  tamponade  as  before 
recommended. 

Hydatiform  Mole  (syncytioma  bc- 
nignum,  vesicular  mole^  myxoma 
chorii). — This  is  a  vesicular  tumor 
within  the  uterus  formed  by  sim- 
ple hyperplasia  or  cystic  degeneration 
of  the  villi  of  the  chorion  at  any 
time  during  pregnancy,  but  most  fre- 
quently in  the  early  months,  and  often 
after  abortion. 

The  accoucheur,  in  considering  the 
symptoms    of    a    supposed    abortion, 


1—12 


178 


ABORTION    (WRIGHT). 


should  ever  keep  in  view  hydatiform 
mole  and  chorion  epithelioma,  because 
early  diagnosis  and  prompt  treatment 
of  both  neoplasms  are  so  extremely  im- 
portant. The  first  symptom  of  the 
former  is  a  discharge  of  a  bloody  fluid 
which  is  sometimes  said  to  resemble 
currant  juice.  Our  first  suspicion  is 
generally  threatened  abortion.  If  the 
discharge  becomes  more  watery  in  ap- 
pearance, if  vesicles  are  expelled,  or 
if  the  uterus  increases  abnormally  in 
size,  v/e  should  suspect  a  vesicular 
mole.  Generally  we  have  to  be  guided 
by  two  symptoms,  hemorrhage,  and  ab- 
normal -increase  in  the  size  of  the 
uterus. 

Treatment  of  Hydatiform  Mole. — 
The  condition  is  serious  and  prompt 
treatment  is  required.  The  uterus 
should  be  emptied  as  soon  as  pos- 
sible. The  following  is  recommended : 
Dilate  the  cervical  canal  with  Hegar's 
dilators,  then  introduce  a  sea-tangled 
tent,  then  plug  the  vagina  as  before 
described.  If  strong  uterine  contrac- 
tions come  on  within  a  short  time  re- 
move the  tampon  and  tent.  If  such 
contractions  do  not  come  on  remove 
the  tampon  and  tent  in  twenty-four 
hours,  then  do  the  uterovaginal  tam- 
ponade as  thoroughly  as  possible. 
This  will,  as  a  rule,  be  sufficient  to 
cause  efficient  uterine  contractions 
which  will  expel  the  mole.  If  there  is 
any  doubt  as  to  such  expulsion  ex- 
plore with  the  finger  gently,  and 
scrape  the  uterine  wall  with  its  tip. 
The  metallic  curette  is  especially  dan- 
gerous in  this  case  because  the  uterine 
walls  are  more  or  less  weakened  by 
the  invasion  of  the  cystic  villi.  Occa- 
sionally it  may  be  advisable  to  use  a 
dull  curette,  but  this  should  be  con- 
sidered a  misfortune,  and  great  care 
should  be  exercised. 


Chorioepithelioma  (chorion  epithe- 
lioma, syncytioma  malignum,  de- 
ciduoma  malignum,  choriocarcinoma). 
— This  is  a  very  malignant  form 
of  epithelioma  developed  from  the 
epithelial  layers  covering  the  villi  of 
the  chorion.  It  is  usually  associated 
with  abortion,  and  in  50  per  cent,  of 
the  cases  is  preceded  by  hydatiform 
mole.  We  are  told  that  it  may  occur 
after  labor  following  full  term,  but 
the  writer  has  not  met  such  a  case. 
Obstetricians  have  for  some  time  con- 
sidered that  this  form  of  epithelioma 
is  always  associated  with -pregnancy. 
Some  surgeons  have  said  recently 
that  tumors  simulating  chorion  epi- 
thelioma have  been  found  not  only  in 
women  in  the  absence  of  pregnancy, 
but  also  in  men,  and  that  all  such 
have  arisen  in  pre-existing"  teratomata. 
Obstetricians,  however,  do  not  believe 
that  such  tumors  are  really  chorio- 
epitheliomata.  Metastatic  deposits, 
even  more  malignant  than  the  original 
tumor,  soon  appear  in  various  parts 
of  the  body,  especially  in  the  vagina 
and  lungs. 

Hemorrhage  is  the  earliest  and  most 
persistent  symptom.  The  flow  is  at 
first  red,  but  soon  becomes  dark  and 
offensive.  The  uterus  grows  rapidly 
and  is  often  perceptibly  soft  in  one 
or  more  places.  A  hemorrhage  is 
serious  when  it  becomes  in  the  slight- 
est degree  offensive.  Scrapings  from 
the  uterine  wall  may  be  examined 
microscopically. 

Treatment  of  Chorion  Epithelioma. — 
A  radical  operation  is  immediately 
indicated.  The  uterus,  appendages, 
and  metastatic  deposits,  especially  if 
any  be  found  in  the  vagina  and  vulva, 
should  be  removed. 

INDUCED  ABORTION.— Induc- 
tion of  abortion  is  very  grave  in  any 


ABORTION    (WRIGHT). 


179 


case,  and  should  never  he  decided  on 
ivitlwut  a  consultation. 

Indications. — It  may  be  said  in  a 
general  way  that,  in  any  case  where 
the  life  of  the  patient  is  imperiled  by 
the  continuation  of  pregnancy,  abor- 
tion should  be  induced.  In  nearly  all 
cases,  however,  w^hen  serious  disease 
is  present  it  should  receive  prompt 
and  careful  treatment.  That  death 
of  the  embryo  or  fetus  is  a  positive 
indication  for  the  induction  of  abor- 
tion need  scarcely  be  emphasized. 

Tuberculosis. — It  was  a  few  years 
ago  (and  is  now  we  fear)  the  custom 
of  some  physicians  to  induce  abortion 
in  all  pregnant  women  suffering  from 
tuberculosis.  We  have  to  consider, 
how^ever,  that  in  the  light  of  our 
present-day  knowledge  tuberculosis 
is  a  curable  disease  in  the  pregnant 
Woman  as  well  as  in  the  non-pregnant 
one.  If,  then,  our  patient  has  tuber- 
culosis during  pregnancy  it  is  our 
duty  to  treat  the  tuberculosis  and  not 
to  murder  the  unborn  child.  This 
should  be  our  general  rule.  In  a  few 
exceptional  cases  (and  they  are  very 
few),  especially  when  the  morbid 
process  is  far  advanced,  the  uterus 
should  be  emptied. 

Cardiac  Disease. — In  a  large  majority 
of  women  who  have  heart  disease, 
pregnancy  does  not  produce  effects 
sufficiently  serious  to  justify  the  in- 
duction of  abortion.  If,  however,  as 
happens  in  a  small  proportion  of 
cases,  especially  when  there  is  mitral 
stenosis,  such  symptoms  as  hemop- 
tysis, precordial  distress,  palpitation, 
and  great  debility  appear,  and  grow 
steadily  worse,  under  appropriate 
treatment,  the  induction  of  abortion 
should  be  considered. 

Excessive  Vomiting  of  Pregnancy. — 
We   have   recently   learned   that   the 


pernicious  vomiting  of  pregnancy  is 
due,  in  some  cases  at  least,  to  peculiar 
disturbances  of  metabolism  which 
produce  a  toxemia.  Chemical  exam- 
ination of  the  urine  shows  a  decrease 
of  the  amount  of  nitrogen  excreted  as 
urea,  and  an  increase  of  the  amount 
excreted  as  ammonia.  In  normal 
pregnancy,  the  quantity  of  ammonia 
excreted  (the  ammonia  coefficient)  is 
4  to  5  per  cent.  In  pregnancy  with 
this  form  of  toxemia,  it  may  rise  to 
10,  20,  or  40  per  cent.,  or  even  higher. 
Williams  thinks  that  when  the  am- 
monia coefficient  exceeds  10  per  cent, 
the  pregnancy  should  be  immediately 
terminated.  We  have  found,  how- 
ever, that  in  some  cases  the  ammonia 
coefficient  may  considerably  exceed 
10  per  cent.,  and  the  patient  may  re- 
cover without  the  termination  of  preg- 
nancy. It  is  hoped  that  further  in- 
vestigation' will  lead  to  conclusions 
which  we  shall  all  accept.  We  agree 
with  Williams  to  some  extent,  how- 
ever, and  believe  that  when  the  am- 
monia coefficient  reaches  10  per  cent, 
the  patient  is  in  a  dangerous  condi- 
tion, and  needs  prompt  and  suitable 
treatment.  If  in  spite  of  such  treat- 
ment carried  out  for  one  to  two  weeks 
she  grows  steadily  worse,  pregnancy 
should  be  terminated. 

The  practitioner  who  does  not  de- 
pend on  this  chemical  test  should  be 
guided  by  the  symptoms  and  condi- 
tion of  the  patient.  Indeed  no  one 
should  neglect  a  careful  study  of  all 
symptoms.  It  is  very  important  that 
we  should  not  wait  too  long.  We 
have  certainly  much  to  learn  yet  re- 
specting this  very  perplexing  subject. 
We  have  occasionally  found  that  the 
results  of  interference  even  in  appar- 
ently favorable  cases  are  sadly  dis- 
appointing. 


180 


ABORTION    (WRIGHT). 


In  hyperemesis  with  marked  and 
progressive  exhaustion,  especially  as 
indicated  by  weekly  loss  of  weight, 
when  the  usual  dietetic  and  medicinal 
measures  have  failed,  no  time  should 
be  lost  in  emptying  the  uterus.  Under 
the  combined  effects  of  toxins  and 
starvation  the  woman's  strength  fails 
insidiously  and  often  the  end  comes 
abruptly.  Lives  are  lost  by  too  long 
delay.  Serious  complications,  advanced 
cardiac  disease  and  certain  others,  em- 
phasize the  necessity  for  intervention. 
Jewett  (N.  Y.  State  Jour,  of  Med., 
Mar.,  1908). 

General  Toxemia  of  Pregnancy. — No 
definite  statement  can  be  made  as  to 
the  exact  time  when  interference  is 
desirable  in  case  of  general  toxemia 
of  pregnancy.  Apart  from  excessive 
vomiting  in  connection  with  toxemia 
we  fear  especially  eclampsia.  Before 
the  onset  of  convulsions  the  induction 
of  abortion  is  very  rarely  considered 
necessary.  Convulsions,  as  a  rule, 
do  not  occur  in  the  early  months  of 
pregnancy;  when  they  occur  in  the 
later  months  an  immediate  delivery 
is  considered  necessary.  A  vaginal 
Caesarean  section  is  probably  safer 
than  rapid  dilatation  of  the  cervix 
with  quick  extraction.  Both  opera- 
tions, however,  are  serious,  and  the 
careful,  conservative  physician  will 
prefer  to  resort  to  safer  procedures. 
The  importance  of  great  haste  in 
emptying  the  uterus  has  been  grossly 
exaggerated  in  recent  years.  We 
think  this  is  especially  true  as  to 
eclampsia. 

Chronic  Nephritis.  —  Induction  of 
abortion  is  not,  as  a  rule,  indicated  in 
cases  of  chronic  nephritis.  Occasion- 
ally the  symptoms  grow  so  serious,  in 
spite  of  suitable  treatment,  that  the 
patient's  life  is  endangered.  Under 
such  circumstances  the  uterus  should 
be  emptied.     Disorders  of  vision  dur- 


mg  pregnancy  are  very  serious  m  pa- 
tients who  have  chronic  interstitial  ne- 
phritis. Partial  or  complete  blindness 
in  such  cases  generally  indicates  a  fatal 
termination.  On  the  other  hand,  one 
may  have  absolute  blindness  due  en- 
tirely to  a  state  of  autointoxication.  In 
such  a  case  the  ophthalmic  changes 
are  not  marked  as  a  rule,  and  the  sight 
generally  returns  soon  after  the  uterus 
is  emptied.  Herringham  (Brit.  Med. 
Jour.,  May  7,  1910)  states  that  this 
transient  form  of  blindness  is  never 
found  in  uremia  or  associated  with 
chronic  interstitial  nephritis. 

Retinitis. — Affections  of  the  eyes 
should  be  carefully  studied.  Retinitis 
should  receive  prompt  attention.  If 
the  symptoms  grow  worse  instead  of 
better  after  treatment  for  a  few  days, 
interference  may  become  necessary.  In 
cases  of  retinitis  with  white  plaques, 
and  dimness  or  loss  of  vision,  asso- 
ciated with  serious  albuminuria,  abor- 
tion should  be  induced  at  once.  Colin 
Campbell  (oculist)  agrees  with  Her- 
ringham and  various  modern  pathol- 
ogists as  to  the  great  difference  be- 
tween a  retinitis  due  to  an  old  chronic 
nephritis  and  a  retinitis  caused  by 
autointoxication  of  pregnancy.  He 
says  the  retinitis  of  pregnancy  has  a 
bright  outlook  compared  with  that  of 
nephritis.  Examination  of  the  urine 
will  materially  aid  a  coming  to  an  un- 
derstanding of  the  condition.  "In  pre- 
existing nephritis  the  quantity  is  usually 
greater,  the  urea  and  nitrogen  more 
nearly  full  normal,  and  the  albumin  and 
casts  more  abundant.  In  pre-eclamptic 
cases  the  uric  acid  and  the  amidoacids 
are  markedly  increased"  (Can.  Jour,  of 
Med.  and  Surg.,  Oct.,  1910).  It  may 
be  stated  in  a  general  way  that  such 
untoward  symptoms  occurring  early 
are   much   more    serious   than   similar 


ABORTION    (WRIGHT). 


181 


Symptoms  which  may  appear  late  in 
pregnancy. 

Pyelitis. — PyeHtis  due  to  toxemia 
of  pregnancy  is  not  very  uncommon, 
althtiugh,  until  recently,  it  was  not 
recognized  as  a  separate  entity.  In- 
terference with  pregnancy  is  not  gen- 
erally required.  If,  however,  the  tem- 
perature keeps  above  normal  for  four 
weeks ;  if  there  is  much  pus  in  the 
urine;  if  the  leucocyte  count  is  high, 
abortion  should  be  induced.  It  is 
better  if  possible,  however,  to  defer 
interference  until  the  child  has  be- 
come viable. 

Antc-partum  Hemorrhages. — Hemor- 
rhage from  placenta  prsevia  is  our  chief 
concern  in  this  connection.  If  inter- 
ference becomes  necessary  we  should 
employ  the  vaginal  tamponade,  and 
should  never  dilate  the  cervix  to  the 
slightest  degree.  If  the  hemorrhage  is 
increased  by  complete  or  partial  sep- 
aration of  a  placenta  normally  situated 
the  same  rule  as  to  treatment  applies. 
Such  hemorrhages  do  not  occur  fre- 
quently before  the  child  is  viable,  and, 
consequently,  need  not  be  discussed  in 
detail  here. 

Retroflexion  of  the  Uterus. — When 
serious  symptoms  appear  because  of 
retroflexion  or  retroversion  of  the 
uterus,  and  the  misplacement  cannot  be 
corrected,  it  may  become  necessary  to 
interfere.  In  the  majority  of  such 
cases  abortion  takes  place  without  any 
interference. 

Contracted  Pelvis. — The  induction  of 
abortion  in  cases  of  contracted  pelvis 
was  for  a  long  time  considered  indi- 
cated. We  hope  it  is  generally  con- 
ceded now  that  such  a  procedure  is 
both  incorrect  and  sinful.  We  have 
learned  in  recent  years  that  conservative 
Cassarean  section,  done  at  the  proper 
time  with  reasonable  care  and  skill,  is 


one  of  the  safest  and  best  operations 
now  known  to  surgery.  Such  having 
been  demonstrated,  we  have  done  well 
in  ceasing  to  destroy  unborn  children 
because  of  contracted  pelvis. 

Hydramnios. — When  the  hyclram- 
nios  causes  the  distention  which  seri- 
ously afl:'ects  the  mother's  health  we 
may  have  to  consider  the  desirability  of 
emptying  the  uterus.  In  such  cases, 
however,  we  can  generally  wait  until 
the  child  becomes  viable. 

Appendicitis,  Ovarian  Tumor,  and 
Other  Abdominal  Grozvths. — Abortion 
should  not  be  induced  for  any  of  these 
conditions.  The  ordinary  operation  for 
the  disease  or  new  growth  should  be 
performed. 

Goiter. — As  a  rule  there  should  be 
no  interference,  at  least  until  the  child 
is  viable. 

Myoma  Uteri. — No  interference  with 
pregnancy -is  indicated  as  a  rule.  In  a 
limited  proportion  of  cases  one  or  more 
fibroids  may  be  so  situated  that  delivery 
in  the  ordinary  way  is  a  physical  impos- 
sibility ;  but,  even  under  such  circum- 
stances, the  induction  of  abortion  is 
very  rarely  indicated.  We  may,  how- 
ever, meet  a  uterus  in  which  the 
growth  would  interfere  with  normal 
delivery,  but  in  this  case  the  child  might 
be  delivered  by  Csesarean  section  if 
pregnancy  went  on  to  term.  Women 
with  very  bad  fibroids  seldom  conceive, 
and  when  they  do  early  abortion  is  apt 
to  occur. 

Chorea. — In  a  certain  proportion  of 
severe  cases  of  chorea  the  patient  goes 
from  bad  to  worse,  notwithstanding 
suitable  treatment.  In  very  serious 
cases  the  woman  grows  worse  very 
rapidly  and  dies  unless  the  uterus  is 
emptied.  In  many  cases  this  serious 
procedure,  unfortunately,  does  not  save 
the  patient. 


1S2 


ABORTION   (WRIGHT). 


The  induction  of  an  abortion  justi- 
fiable in  pernicious  hyperemesis,  in 
some  cases  of  chorea,  in  certain  forms 
of  convulsive  seizures,  nephritis  pre- 
ceding or  manifesting  itself  early  in 
pregnancy,  and  in  certain  cases  of 
contracted  pelvis.  If  the  well-knov/n 
bougie  method  does  not  bring  about 
the  desired  result  in  from  twenty-four 
to  forty-eight  hours,  it  may  be  sup- 
planted with  a  tampon  of  gauze  carried 
into  the  uterine  interior.  H.  J.  Boldt 
(Jour.  Am.  Med.  Assoc,  Mar.  17,  1906). 

Method  of  Inducing  Abortion. — For 

the  inckiction  of  abortion  we  employ  the 
methods  and  procedures  generally  used 


Amnionic  sac  containing  embryo  and  waters. 
The  thick  decidua  retained  in  uterus.  (Seven 
weeks.) 


in  cases  of  inevitable  abortion  (see  p. 
165).  When  speaking  about  the  treat- 
ment of  the  latter  we  had  in  view  the 
fact  that  nature,  chiefly  through  uterine 
contractions,  and  hemorrhages,  had 
done  something,  perhaps  much,  in  the 
process  of  abortion.  The  ovum  has 
been  more  or  less  loosened  from  its  at- 
tachments, and  the  cervix  has  perhaps 
been  more  or  less  dilated.  In  consider- 
ing the  induction  of  abortion,  we  as- 
sume, on  the  other  hand,  that  the  ovum 
is  pretty  firmly  attached  to  its  moorings, 
and  that  the  cervical  canal  is  not  dilated. 
Under  such  circumstances  it  is  more 
difficult  to  empty  the  uterus.  The  fol- 
lowing recommendations  are  made  for 
the  induction  of  abortion  at  different 


periods  of  pregnancy  up  to  the  seventh 
month.  This  course  seems  advisable, 
although  it  will  mean  a  certain  amount 
of  repetition : — 

In  any  case  prepare  the  patient  as  for 
vaginal  hysterectomy,  or  as  before 
described,  for  curettage  (see  p.  173). 


Pregnancy,  three  months,  showing  fetus 
below.    Placenta  formed. 


First  or  Second  Month. — Introduce 
a  vaginal  tampon  of  iodoform  cheese- 
cloth as  before  described.  This  may  be 
removed,  and  reintroduced,  every 
twenty-four  hours  for  five  or  six  days. 
In  many  cases  these  vaginal  tampons 
will  not  produce  the  desired  result,  even 
in  five  or  six  days.  Under  such  cir- 
cumstances one  may  introduce  a  narrow 
strip  of  iodoform  gauze  within  the 
uterus  after  the  first  or  second  day. 
If,  in  doing  this,  one  punctures  the  mem- 


ABORTION    (WRIGHT). 


183 


brane.  no  serious  harm  will  be  clone. 
After  such  introduction,  practise  vagi- 
nal tamponade.  It  may  be  necessary 
to  do  more  than  the  introduction  of  the 
gauze;  if  so,  adopt  the  old-fashioned 
method  of  introducing  a  uterine  sound, 
and  purposely  puncture  the  membranes 
if  possible.  This  is  suitable,  especially 
in  cases  of  pernicious  vomiting,  because 
such  puncture  allows  tlie  escape  of  the 
liquor  amnii,  and  such  escape  often 
causes  the  serious  symptoms  to  subside 
immediately.  It  happens  that  in  certain 
cases  it  is  difficult  to  puncture  the  mem- 
branes because  the  deciduum  is  thick, 
tough  and  elastic. 

Tliird  Month.  —  Carry  out  the 
methods  recommended  for  the  first  and 
second  months.  There  is  less  chance 
of  causing  the  expulsion  of  the  entire 
ovum  and  on  that  account  it  is  not  well 
to  w^ait  long  before  invading  the  interior 
of  the  uterus. 

FourtJi  and  Fifth  Months. — Practise 
a  uterovaginal  tamponade  as  before 
described  as  rapidly  and  thoroughly  as 
possible. 

SixtJi  and  Seventh  Months. — Intro- 
duce a  vaginal  tampon,  remove  in 
twenty-four  hours,  place  patient  in 
lithotomy  "across  bed"  position:  intro- 
duce a  weight  speculum,  seize  the 
anterior  lip  of  the  cervix,  pass  a  gum- 
elastic  or  hard-rubber  bougie,  or  a 
medium-sized  rectal  tube  within  the 
uterus,  between  the  membranes  and 
uterine  wall  to  the  fundus  if  possible. 
Then  place  woman  in  Sims's  position, 
and  plug  vault  of  the  vagina  tightly. 
Labor  will  generally  come  on  in  a  few 
hours,  and  the  uterine  contents  will 
soon  be  expelled.  It  is  sometimes  ad- 
visable to  introduce  the  bougie  in  the 
fifth  month. 

We  find  that  in  some  cases  the  tam- 
ponades are  not  efficient,   and  we   are 


compelled  to  adopt  more  forceful  pro- 
cedures. As  before  mentioned  we  think 
the  use  of  the  metallic  dilator  and  sharp 
curette  in  the  "single  sitting"  operation 
is  always  dangerous.  If  this  statement 
is  true,  or  even  half-true,  it  is  sad  to 
notice  that  some  of  our  ablest  authors 
in  recent  textbooks  say  that  "the  in- 
duction of  abortion  is  practically  free 
from  danger  if  perfect  asepsis  is 
observed."  This  operation  is  especially 
dangerous  in  the  class  of  cases  included 
in  this  chapter  because  the  patient  is 
generally  in  a  bad  physical  condition 
from  the  complication  which  calls  for 
the  termination  of  pregnancy,  as,  for 
instance,  pernicious  vomiting. 

It  is  generally  an  easy  matter,  espe- 
cially after  a  vaginal  tampon  has  been 
in  place  twenty-four  hours,  to  dilate  the 
cervix  with  the  Hegar  dilators  suffi- 
ciently to  allow  the  introduction  of  the 
gauze  within  the  uterine  cavity.  We 
also  recommended  the  use  of  the 
laminaria  (sea-tangle)  tent  for  dilata- 
tion. It  is  said,  however,  that  there  is 
great  danger  of  infection  from  the  use 
of  any  tent  for  such  purpose.  There 
was,  of  course,  much  reason  for  such 
fear  many  years  ago  when  the  sponge, 
tupelo  and  laminaria  tents  were  not 
sterile,  and,  in  addition,  were  not  used 
in  an  aseptic  way;  but  during  recent 
years  we  have  been  able  to  get  excellent 
sterile  laminaria  tents  that  are  perfectly 
safe  if  used  in  a  cleanly  way. 

Similar  objections  have  been  raised 
against  tampons  because  they  also  were 
unsafe  as  used  many  years  ago,  but  the 
tampon  medicated  with  iodoform  or 
other  suitable  antiseptic  is  as  safe  as 
anything  that  can  be  introduced  within 
the  uterine  cavity.  It  is  thought  by 
some  that  there  is  danger  from  the  use 
of  the  bougie  according  to  Krause's 
method,  but,  if  the  bougie  is  made  per- 


184 


ABORTION,   TUBAL    (DEAVER). 


fectly  sterile  by  boiling  and  is  carefully 
used,  the  danger  therefrom  is  very 
slight.  It  is  well  to  remember,  how- 
ever, that  there  is  always  some  danger 
in  connection  with  any  obstetrical 
operation  through  want  of  care  on  our 
part.  We  should  ever  make  a  con- 
tinuous effort  to  guard  against  such 
danger. 

A.  H.  Wright, 

Toronto. 

ABORTION,    TUBAL.— 

DEFINITION.— Early  interruption, 
i.e.,  abortion,  is  the  natural  outcome 
of  extra-uterine  pregnancy,  whether 
by  reasons  of  insufficient  blood- 
supply  or  unfavorable  mechanical 
conditions  for  the  continued  develop- 
ment of  the  fetus. 

[A  brief  review  of  the  history  of  this  im- 
portant suijject  ought  to  possess  for  us  more 
than  ordinary  interest  because  of  the  impor- 
tant role  played  in  its  development  by  one 
almost  of  our  own  number  and  generation 
in  whom  we  may  take  a  pardonable  local 
pride.  I  refer  to  the  illustrious  and  lamented 
John  S.  Parry.  He  was  not  the  first  to  write 
upon  the  subject.  Indeed,  Albucasis,  the 
Arabian,  in  th"e  eleventh  century  recognized 
and  described  a  case  of  extra-uterine  preg- 
nancy. Nor  was  he  the  first  to  grasp  the 
possibilities  of  operative  treatment  in  the 
emergency  of  rupture.  That  was  proposed 
by  Harbert,  of  New  York,  in  1849.  The 
merit  of  Parry  consisted  not  only  in  grasping 
the  significance  of  the  catastrophe  and  the 
correct  mode  of  meeting  the  emergency,  but 
in  applying  his  philosophical  mind  and  schol- 
arly attainments  to  the  production  of  a  mono- 
graph which  by  its  masterly  marshaling  of 
facts  and  lucidity  of  deduction  should  have 
quieted  the  doubts  of  Thomas.  He  was  able 
to  collect  for  his  book,  which  was  published 
in  1876,  500  cases  reported  in  the  literature. 
Of  499,  in  which  the  result  was  stated,  366 
died  and  163  recovered.  Of  the  deaths,  174 
had  been  from  rupture.  Of  these  deaths  81 
had  died  within  24  hours.  These  figures 
were  his  text.  He  began  his  sermon  with 
this    sentence :     "From    the    middle    of    the 


eleventh  century,  when  Albucasis  described 
the  first  known  case  of  extra-uterine  preg- 
nancy, men  have  doubtless  watched  the  life 
ebb  rapidly  from  the  pale  victim  of  this  acci- 
dent, but  have  never  raised  a  hand  to  help 
her."  Then,  though  not  himself  a  surgeon, 
he  points  out  the  plain  surgical  indications. 
In  the  same  year  as  the  publication  of  his 
monograph  he  died,  doubtless  depriving  the 
world  of  one  who  was  destined  to  become 
one  of  its  greatest  figures  in  the  advance- 
ment of  medicine.  Parry  was  a  pupil  of  my 
father,  who  often  used  to  speak  of  his  stu- 
dious habits  and  scholarly  grasp.  He  was 
by  nature  fitted   for  mental  leadership. 

The  honor  of  performing  the  first  opera- 
tion for  this  emergency  went  to  Lawson  Tait 
in  1883.  He  had  been  earnestly  solicited  to 
operate  for  this  condition  in  1881  by  a  physi- 
cian who  had  correctly  diagnosed  a  case  of 
rupture  with  internal  hemorrhage.  He  re- 
fused, and  the  patient  died  shortly  after. 
Unfortunately  the  first  patient  operated  on 
died  also,  but  his  change  of  heart  was  com- 
plete, and,  correctly  attributing  his  failure  in 
the  first  case  to  faulty  technique,  he  altered 
his  method  and  continued  to  operate  all  such 
cases.  Of  the  next  40  cases  only  1  died. 
Truly  a  brilliant  record  which  was  not  long 
in  converting  the  medical  fraternity. 

The  original  microscopical  preparations  of 
Tait  in  which  he  demonstrated  his  ideas  on 
extra-uterine  pregnancy  and  pelvic  hemato- 
cele which,  before  him,  were  in  a  very  con- 
fused state  are  still  to  be  seen  in  the  mu- 
seum of  the  Royal  College  of  Physicians  in 
London. 

There  are  many  other  names  of  more  or 
less  importance  in  connection  with  the  de- 
velopment of  the  subject,  but  these  two  are 
central  and  all  we  have  space  to  consider. 
John  B.  Deaver.] 

SYMPTOMS.— The  symptoms  of 
extra-uterine  pregnancy  include  those 
due  solely  to  the  condition  of  preg- 
nancy and  those  which  arise  only 
from  its  abnormal  situation.  Inas- 
much as  the  majority  of  cases  termi- 
nate within  three  months,  at  which 
ordinary  signs  of  pregnancy  are  not 
usually  pronounced,  we  do  not  often 
get  much  help  from  the  symptoms 
belonging    to    the    first    group.      Yet 


ABORTION,    TUBAL    (DEAVER). 


185 


such  symptoms  and  signs  as  enlarge- 
ment of  the  breasts,  the  presence  of 
colostrum,  cessation  of  menstruation, 
increased  vascularity  of  the  genitalia, 
softening"  of  the  cervix  and  body  of 
the  uterus  with  slight  enlargement, 
disturbances  of  the  bowels  or  bladder, 
morning  nausea,  and  the  abnormal 
appetite,  cravings  or  sensations  which 
the  multipara  sometimes  recognizes, 
are  occasionally  of  confirmatory  value. 
It  would  be  desirable  to  make  the 
diagnosis  before  rupture  were  it  pos- 
sible to  do  so.  Unfortunately  a  large 
percentage  of  cases  give  such  trifling 
evidence  of  the  true  condition,  if 
indeed  there  be  any  prodromal  symp- 
toms at  all,  that  no  suspicion  is 
aroused.  Still  it  is  occasionally  pos- 
sible to  make  the  diagnosis  and  it 
should  be  our  efl'ort  to  do  so.  One 
operator,  Baldwin,  of  Columbus, 
Ohio,  has  reported  11  such  cases. 

A  prolonged  continuous  blood-stained 
uterine  discharge  is  an  important  aid 
in  differentiating  tubal  abortion;  even  if 
the  proportion  of  blood  is  small  its 
persistence  for  two  up  to  five  weeks  is 
characteristic,  and  absence  of  blood  in 
the  vaginal  discharge  is  strong  evidence 
against  a  recent  hematocele.  The  sHght 
hemorrhage  seems  to  persist  longer 
after  tubal  abortion  than  after  rup- 
ture. Incomplete  expulsion  of  the 
ovum  is  also  liable  to  keep  up  the 
hemorrhagic  discharge,  and  the  writer 
relates  some  instances  of  such  reten- 
tion of  the  placenta  with  the  tube  open 
and  of  total  retention  with  the  tube 
closed.  The  small  encapsulated  collec- 
tion of  blood  may  be  taken  for  a 
^  fibroma,  and  the  resulting  disturbances 
for  inflammatory  processes  in  the  ad- 
nexa  or  in  the  uterus.  Certain  cases 
of  tubal  abortion  have  been  diagnosed 
as  a  hemorrhagic  metritis,  and  the 
uterus  was  curetted  when  this  organ 
was  sound  and  the  trouble  was  in  the 
tube  beyond  the  reach  of  the  curette. 
F.  Lejars  (Semaine  medicale,  July  13, 
1910). 


A  new  sign  of  tubal  pregnancy  is 
a  more  or  less  striking  paleness  of  the 
cervix.  The  absence  of  this  paleness 
does  not,  however,  exclude  this  condi- 
tion, but  its  presence,  when  not  due  to 
obvious  other  causes,  is  almost  pathog- 
nomonic. It  is  only  present,  however, 
in  those  cases  of  tubal  gestation  in 
which  there  is  bleeding  from  the  uterus, 
and  onl}'  while  this  bleeding  is  actively 
going  on.  Golden  (W.  Va.  Med.  Jour., 
May,  1911). 

The  diagnosis  in  these  cases  rests 
upon :  first,  a  consideration  of  the  his- 
tory. Important  points  for  considera- 
tion are  the  age  of  the  patient, 
exposure  to  pregnancy  and  the  pre- 
sumptive signs  and  symptoms,  a 
history  indicative  of  an  antecedent 
tubal  inflammation,  a  previous  period 
of  sterility  usually  of  some  years. 
This  last  point  has  been  observed  by 
all  students  of  the  condition  and 
Parry  remarks  on  what  he  calls  "the 
previous  inaptitude  for  conception" 
of  these  patients. 

Amenorrhea  of  shorter  or  longer 
duration  is  a  fairly  constant  feature 
and  is  followed  in  the  majority  of 
instances  by  irregular  bleeding  from 
the  uterus,  sometimes  profuse,  some- 
times a  mere  staining.  The  history 
of  passing  bits  of  tissue  or  the  demon- 
stration of  decidua  in  the  discharge 
is  important. 

Pain  if  felt  before  rupture  consists 
frequently  in  vague  uneasy  sensa- 
tions in  the  pelvis.  Sometimes  it  is 
more  severe,  colicky  in  type  and  ac- 
companied b}'  nausea. 

In  cases  which  show  any  of  these 
suspicious  symptoms  an  internal  ex- 
amination should  not  be  neglected. 
The  demonstration  of  a  pelvic  mass 
lying  outside  of  the  uterus,  in  the 
presence  of  a  probable  pregnancy,  is 
a  very  suspicious  circumstance.  If 
this  mass  should   correspond  in  size 


186 


ABORTION,    TUBAL    (DEAVER). 


with  the  duration  of  pregnancy,  if  it 
should  be  located  in  the  course  of 
the  tube,  if  it  be  movable,  moderately 
soft  and  very  tender,  we  may  fairly 
conclude  we  are  dealing  with  a  case 
of  extra-uterine  pregnancy.  It  must 
be  remembered  that  it  is  sometimes 
easy  to  mistake  a  retroflexed  preg- 
nant uterus  for  an  extra-uterine  preg- 
nancy. 

Review  of  36  cases  simulating  tubal 
pregnancy.  The  following  conditions 
may  be  mistaken  for  the  latter :  1, 
an  acute  exacerbation  of  a  dormant 
gonorrheal  pyosalpinx ;  2,  sudden  ex- 
tension of  a  uterine  gonorrhea  to  the 
tubes  and  peritoneum ;  3,  an  early  abor- 
tion if  associated  with  salpingitis  or  a 
tumor;  4,  an  irregularly  softened,  mis- 
placed, hyperesthetic  uterus  associated 
with  tubal  enlargement;  5,  an  unsus- 
pected tumor  associated  with  symptoms 
of  early  pregnancy;  6,  ovarian  hemor- 
rhage or  tubal  hemorrhage  from  other 
conditions ;  7,  sudden  and  rapidly  pro- 
gressive salpingitis,  appendicitis,  and 
gastrointestinal  perforations.  Crossen 
(Jour.  Amer.  Med.  Assoc,  Feb.  12, 
1910). 

Often  before  a  diagnosis  can  be 
made,  usually  before  the  diagnosis  is 
made  rupture  of  the  tube  or  extensive 
separation  and  hemorrhage  from  the 
placental  site  supervenes.  It  was 
formerly  thought  that  rupture  was 
the  most  common  outcome  of  tubal 
pregnancy.  More  careful  examina- 
tion of  the  specimens,  however,  has 
shown  us  that  in  many  cases  of  sup- 
posed rupture  we  are  dealing  with  a 
case  of  tubal  abortion  with  hemor- 
rhage from  the  site  of  implantation. 
Moreover,  hemorrhage  from  this 
source,  while  less  violent  as  a  rule 
than  in  rupture,  may  be  very  severe 
and  even  fatal.  Frequently,  however, 
it  is  comparatively  slow  and  by  slow 
leakage  is  responsible  for  the  majority 
of  hematoceles  which  we  find.  Recent 


statistics  indicate  that  these  tubal 
abortions  occur  more  frequently  than 
does  rupture.  The  tragic  stage,  how- 
ever, may  follow  either  process. 

[The  idea  that  rupture  is  not  so  frequent 
as  has  been  supposed  and  therefore  an  extra- 
uterine pregnancy  is  not  so  dangerous  a 
condition  is  fallacious.  It  is  a  matter  of 
common  knowledge  that  tubal  abortion  may 
give  rise  to  a  condition  as  serious  as  any  of 
the  accidents  of  ectopic  pregnancy.  I  should 
not  feel  it  necessary  to  insist  on  this  fact 
were  it  not  for  an  impression  which  is  going 
abroad  in  regard  to  treatment,  which  I  shall 
consider   later.     John    B.    Deaver.] 

A  positive  diagnosis  before  a  rupture 
has  been  rare,  but  there  are  many  in- 
stances in  which  a  strong  presumptive 
diagnosis  should  have  been  made  and 
for  lack  of  which  the  patient  suffers. 
Most  cases,  however,  do  not  come  under 
the  physician's  notice  until  rupture,  the 
symptoms  being  not  much  different 
from  those  of  normal  pregnancy. 
There  is  usually  a  cessation  of  men- 
struation for  one  or  more  periods,  and 
in  this  case,  with  rupture  threatening,  it 
is  usually  re-established,  irregular  as  to 
time,  and  of  a  tarry,  sticky  character 
which,  according  to  some  observers,  is 
pathognomonic.  The  pain  is  usually 
cramp-like,  occurring  at  intervals  for 
several  days,  and  following  it  there  is 
a  dark,  sanguineous  discharge,  probably 
due  to  a  partial  rupture  of  the  gesta- 
tion sac.  Microscopic  examination  will 
reveal  traces  of  decidua  in  most  cases. 
While  the  history  of  the  case  is  im- 
portant, a  careful  and  thorough  exam- 
ination is  advisable  and  great  care 
should  be  employed  to  avoid  rupturing 
the  sac.  The  rupture  in  the  doctor's 
office  is  a  frightful  accident — one  which 
greatly  involves  his  responsib'lity.  L. 
G.  Bowers  (Jour.  Amer.  Med.  Assoc, 
Feb.  12,  1910). 
Rupture  is  the  most  serious  acci- 
dent of  ectopic  gestation.  It  may 
take  place  very  early  and  be  the  first 
symptom.  Cases  have  been  reported 
of  rupture  in  the  first  or  second  weeks 
of  pregnancy.  Usually  it  occurs  in 
the  second  or  third  months,  but  occa- 


ABORTION,   TUBAL    (DEAVER). 


187 


sionally  may  be  delayed  into  the  later 
months.  Secondary  rupture  may  oc- 
cur at  any  time  after  primary  rupture 
up  to  term.  Rupture  is  usually 
ushered  in  by  severe  lancinating  pain 
in  the  hypogastrium,  accompanied  by 
shock,  sometimes  by  syncope  and 
frequently    by    nausea    or    vomiting. 


of  the  abdomen  which  is  readily  dis- 
tinguished from  the  usual  rigidity  of 
inflammation  of  the  peritoneum. 

There  are  the  symptoms  of  rupture 
and  of  hemorrhage  per  se.  They  are 
not  always  so  frank  and  outspoken 
and  in  order  to  be  sure  of  our  ground 
it  is  frequently  necessary  to  bring  to 


Differential   Diagnosis    between    Extra-uterine    Pregnancy   and    Early 
Abortion  Based  on  a  Careful  Study  of  28  Cases. 


Extra-uterine  Pregnancy. 

1.  Advent  is  sudden. 

2.  Pain  is  severe  very  early. 

3.  Blanching  of  the  face  early. 

4.  Pulse  very  feeble  and  rapid  early. 

5.  Hemorrhage  usually  not  severe,  but  per- 

sists,  even    after   the    uterus   has   been 
thoroughly  emptied. 

6.  At    iirst   there    is    no    elevation    of    tem- 

perature,  and   later   it   is   rarely   above 
101°  F. 

7.  At  one  side  of  the  uterus  there  is  usu- 

ally a  very  tender  tumor,  which  is,  as 

a  rule,  movable. 
%.  Boggy   feeling  behind  the  uterus. 
9.  Usually  the  cervix  is  very  slightly  open. 

10.  Shreds,    decidual    membrane    and    blood 

only  escape. 

11.  Late  there  will  be  marked  diminution  of 

the  hemoglobin   (30  per  cent,  to  70  per 
cent.). 

12.  Rarely,  if  ever,  polynuclear  leucocytes. 


13.  If  the  cul-de-sac  of  Douglas  is  opened, 
blood  will  escape  with  possibly  an 
embryo. 

Ralph    Waldo    (Archives    of    Diag.,    Oct.,    1908) 


Early  Abortion  in  Uterine  Pregnancy. 

Rarely  sudden. 

Not  severe  early. 

Blanching  of  the  face  late,  if  ever. 

Pulse  strong  and  full  until  late. 

Hemorrhage  usually  severe  early  and  mark- 
edly, diminishes  after  the  uterus  is  emptied 
and  ceases  entirely  in  a  few  days. 

Frequently,  especially  if  there  is  sepsis,  the 
temperature  is   very  much   elevated. 

There  is  no  tumor  unless  there  is  infection, 
and  then  it  is  rarely  movable. 

Not  present. 

It  is  open,  especially  if  part  of  the  products 
of  conception  are  still  in  the  uterus. 

An  embryo  may  be  found;  if  not,  the  mi- 
croscope will  show  chorionic  villi. 

No  marked  diminution  of  hemoglobin. 


Frequently  present,  especially  if  there  is  in- 
fection. 
No  blood  will  escape. 


Following  this  the  symptoms  of  in- 
ternal hemorrhages  make  their  ap- 
pearance. Increasing  pallor,  rapid 
and  weak  pulse,  sighing  and  labored 
respiration  and  air  hunger,  dimming 
of  vision,  with  increasing  but  slight 
distention  of  the  abdomen,  signs  of 
fluid  in  the  flanks,  general  abdominal 
tenderness  most  marked  in  the  hypo- 
gastrium  and  a  peculiar  doughy  feel 


our  aid  the  history  and  the  internal 
examination.  In  this  condition  as  in 
so  many  others,  the  classical  picture 
in  toto  is  rarely  seen  and  it  has 
happened,  paradoxically  enough,  as 
Douglas  remarks,  that  many  more 
diagnoses  are  made  nowadays  since 
the  integrity  of  all  the  classical  symp- 
toms have  been  repeatedly  attacked 
than  when  a  clear  average  picture  had 


188 


ABOEIION,    TUBAL    (DEAVER). 


been  drawn  and  accepted.  It  will  do 
then  to  know  that  the  three  cardinal 
symptoms  are  pain,  menstrual  irregu- 
larities and  tumor  if  we  appreciate 
their  variability. 

Conclusions  based  on  a  study  of  214 
cases :  1.  Irregular  flowing  seems  to 
play  the  important  part  given  it  in  the 
books  as  a  symptom  of  extra-uterine 
pregnancy.  2.  The  importance  of  a 
long  period  of  sterility  as  a  cause  of 
extra-uterine  pregnancy  does  not  seem 
to  be  borne  out  by  these  statistics.  3. 
Conditions  possibly  leading  to  extra- 
uterine pregnancy:  The  fact  that  cystic 
ovaries,  disease  of  the  opposite  tube, 
adhesions,  or  a  previous  miscarriage 
occurred  in  over  83  per  cent,  of  202 
cases  is  suggestive,  and  is  in  agree- 
ment with  authorities  as  to  the  possible 
relation  of  such  conditions  to  extra- 
uterine pregnancy.  4.  The  fact  that  in 
only  26.5  per  cent,  of  207  cases  the  pain 
was  sudden  is  of  interest.  In  about 
three-fourths  of  the  cases  the  sudden 
severe  pain  was  preceded  by  pain  of  less 
severity,  coming  on  gradually.  5.  Of 
considerable  interest  is  the  leucocytosis 
observed  in  the  cases  in  shock.  This 
is  apparently  a  perfect  example  of  leu- 
cocytosis after  hemorrhage.  The  find- 
ing of  a  temperature  of  100°  or  over  in 
43.4  per  cent,  of  the  cases,  and  of  a 
temperature  of  101°  or  over  in  14.4  per 
cent,  of  cases,  is  also  of  interest.  Ordi- 
narily it  is  supposed  these  cases  rarely 
have  any  fever.  Coues  (Boston  Med. 
and  Surg.  Jour.,  May  11,  1911). 

[The  question  of  great  and  timely  interest 
in  connection  with  the  treatment  of  extra- 
uterine pregnancy  has  to  do  with  the  man- 
agement of  the  case  at  the  time  of  rup- 
ture, with  associated  hemorrhage  and  shock. 
Thanks  to  the  early  operation  these  com- 
plications are  rare  nowadays,  but  I  fear,  if 
the  advocates  of  delayed  treatment  secure  a 
following  in  the  profession,  that  these  cases 
may  occur  more  frequently,  and  that  cases 
which  would  be  noted  in  the  statistics  of 
extreme  conservatives  as  cures  will  later 
succumb  to  a  condition  which  is  the  direct 
result  of  the  Fabian  policy.  John  B. 
Deaver.] 


COMPLICATIONS.— I  have  al- 
ready pointed  out  that  spontaneous 
cures  may  occur  without  leaving-  a 
dangerous  condition  behind  and  have 
remarked  on  the  rarity  of  such  a 
favorable  outcome.  More  usual  is  it 
for  a  collection  of  blood,  often  very 
large,  to  be  left  as  a  foreign  body  in 
the  peritoneum. 

These  collections  or  hematoceles 
excite  a  reactive  peritonitis  which 
serves  to  glue  together  the  intestines 
and  encapsulate  the  mass  of  clots. 
Absorption  and  organization  of  such 
a  clot  may  take  place,  but  is  usually 
very  slow.  In  the  mean  time  not  in- 
frequently infection  occurs.  The 
danger  of  this  is  apparent  when  we 
realize  that  an  hematocele  is  nothing 
but  a  most  inviting  medium  for  bac- 
terial growth,  situated  about  the 
rectum  or  lower  bowel,  which  harbors 
the  most  virulent  bacteria. 

[An  infected  hematocele  is  a  serious  con- 
dition and  demands  prompt  evacuation  and 
drainage.  This  is  best  done  by  way  of  the 
vagina,  if  possible.  At  times  it  is  necessary 
to  attack  it  by  the  abdominal  route,  accept- 
ing the  danger  of  a  subsequent  peritonitis. 
John  B.  Deavee.] 

Obstruction  of  the  bowel  is  men- 
tioned by  Parry  as  the  cause  of 
death  in  a  number  of  instances.  The 
mechanism  of  this  is  by  the  peritoneal 
adhesions  set  up  by  the  old  extrava- 
sation of  blood  or  a  degenerated  fetus 
in  neglected  cases. 

Case  of  extra-uterine  gestation  sac 
which  ruptured  into  the  large  intestine. 
A  five-months  fetus  with  cord  and 
placenta  was  passed  from  the  rectum, 
and  the  patient  .recovered.  Martin 
(Munch,  med.   Woch.,  Aug.  21,   1906). 

A  pregnancy  which  is  allowed  after 
rupture  to  develop  free  in  the  ab- 
domen or  in  the  broad  ligament  later 
furnishes  a  very  difficult  problem  to 


ABORTION,   TUBAL    (DEAVER). 


189 


the  surgeon  owing  to  the  danger  in 
dealing  with  the  placental  site,  and 
the  mortality  in  such  cases  is  much 
higher  than  in  the  early  cases.  Left 
entirely  to  itself  the  fetus  often  be- 
comes infected,  and  the  earliest 
records  we  have  of  extra-uterine  preg- 
nancies are  of  cases  in  which  this  oc- 
curred, the  resulting  abscess  later 
spontaneously  discharging  through 
.the  abdominal  walls,  when  its  nature 
was  surmised  by  the  appearance  of 
degenerated  fetal  parts  in  the  dis- 
charge. Sepsis,  exhaustion  and  death 
were  noted  in  54  of  Parry's  cases. 

Case  of  ruptured  ectopic  pregnancy 
which  presented  the  combination  of  a 
ruptured  ectopic  pregnancy  in  which  the 
following  points  of  interest  were  noted: 

1.  Recovery  following  a  ruptured  ec- 
topic gestation  with  a  streptococcus  in- 
fection of  the  sac  and  the  peritoneal 
cavity,  with  a  patient  so  alarmingly  ill. 

2.  The  presence  of  the  indurated  mass 
in  the  right  quadrant  of  the  abdomen 
which  suggested  an  inflammatory  con- 
dition, although  in  consequence  of  the 
finding  of  the  streptococcus  in  the  cul- 
de-sac  and  the  cavity  of  the  uterus  an 
abdominal  section  seemed  to  be  inad- 
visable at  the  time  of  the  first  operation. 

3.  The  finding  of  streptococci  in  tha 
fluid  aspirated  from  the  abdominal 
mass,  showing  that  the  peritonitis  was 
spreading  and  calling  for  an  immediate 
abdominal  operation.  Hunter  Robb 
(Cleveland  Med.  Jour.,  April,  1911). 

ETIOLOGY  AND  PATHOGEN- 
ESIS.— In  attempting  to  get  a  clear 
idea  concerning  the  causation  of 
extra-uterine  pregnancy,  one  is  quite 
awed  and  overcome  by  the  vast 
number  of  hypotheses  which  have 
been  advanced  to  account  for  this 
curious  anomaly. 

[It  reminds  us  of  the  wealth  of  therapeutic 
suggestions  with  which  we  are  favored  in 
the  case  of  diseases  as  yet  ;-esistant  to  all 
modes   of  treatment.     It   is   not   surprising 


that  there  is  still  considerable  obscurity  in 
the  etiology.  A  correct  understanding  of 
the  pathology  of  any  condition  presupposes 
a  fairly  exact  knowledge  of  the  normal  phys- 
iology of  the  parts.  There  still  exist  many 
problems  connected  with  maturation,  ovula- 
tion, impregnation,  implantation  and  devel- 
opment. Some  of  these  problems  carry  us 
well  back  into  the  shadowy  realms  of  the 
beginnings  of  life  itself,  that  ultima  Thule 
of  the  biologist. 

The  incompleteness  of  our  information 
concerning  these  abstruse  secrets  of  nature 
forces  us  here,  as  in  so  many  other  medical 
problems,  to  resort  to  the  methods  of  induc- 
tion and  experience,  and  if  we  have  not  yet 
arrived  at  the  point  where  we  may  safely 
take  the  inductive  hazard  it  is  because  we 
may  not  yet  have  appreciated  fully  the  say- 
ing of  old  Ambroise  Pare  that  "such  matters 
cannot  be  determined  by  sitting  down  and 
thinking,  but  by  hard  unremitting  toil." 

Gradually,  however,  our  knowledge  of  the 
normal  functions  of  procreation  has  been 
expanding  and  a  sufficient  number  of  cases 
have  been  observed,  recorded  and  analyzed 
to  enable  us  to  recognize  certain  factors 
which  evi'dently  play  an  important  part  in 
the  etiology.    John  B.    Leaver.] 

Lawson  Tait  originally  thought 
that  the  ciliary  current  of  the  mucous 
membrane  of  the  tubes  and  that  of 
the  uterus  was  in  opposite  direc- 
tions, that  of  the  tubes  being  directed 
toward  the  uterus  and  that  of  the 
uterus  moving  upward,  thus  forming 
a  natural  meeting  place  of  sperm  and 
ovum  at  the  fundus.  He*considered 
it  abnormal  for  spermatozoa  to  gain 
an  entrance  into  the  tubes  and  held 
that  impregnation  occurring  in  the 
tubes  through  this  accidental  invasion 
of  the  spermatozoon  was  very  likely 
to  give  rise  to  tubal  pregnancy.  This 
beautifully  simple  conception  has 
yielded  to  the  iconoclastic  power  of 
observed  facts.  We  now  know  that 
the  ciliary  current  of  the  uterus  as 
well  as  that  in  the  tubes  is  downward. 
We  know  that  the  spermatozoa  can 


190 


ABORTION,   TUBAL    (DEAVER). 


readily  stem  this  current,  their  rate 
of  speed  being"  calculated  by  Henle 
as  1  cm.  in  three  minutes. 

We  know  that  they  quite  regularly 
obtain  entrance  into  the  tubes  and 
swarm  up  its  lumen  and  it  seems 
quite  probable,  if  not  certain,  that 
impregnation  in  the  tube  is  common, 
if  not  the  regular  method.  Once 
fertilization  has  taken  place  develop 
ment  begins  at  once.  The  ovum, 
comparable  in  many  respects  to  a 
parasite,  rapidly  throws  out  the  chori- 
onic villi  which  lay  hold  on  the 
maternal  tissues  and  by  erosion 
secure  anchorage  and  open  up  the 
intervillous  blood  spaces.  Just  how 
soon  the  ovum  displays  these  grasp- 
ing tendencies  is  unknown.  The 
•  youngest  ovum  of  which  we  know 
was  discovered  by  Peters  in  the 
uterus  of  a  woman  who  committed 
suicide  three  days  after  missing  her 
period.  It  measured  .6  x  .8  x  1.3  milli- 
meters and  was  firmly  implanted  with 
numerous  projecting  villi  in  the 
process  of  formation.  Certainly  this 
ovum  was  less  than  a  week  old.  Just 
what  condition  must  be  met  by  the 
maternal  tissues  to  permit  of  implan- 
tation is  uncertain.  Webster  is  quite 
certain  that  there  must  be  a  decidual 
reaction  and  a  number  of  observers 
have  reported  having  seen  decidual 
formation  in  the  tubes. 

Normally  the  oosperm  is  swept 
down  into  the  uterus  before  it  effects 
a  lodgment.  The  forces  which  accom- 
plish this  movement  are  the  peristalsis 
of  the  tube  and  the  action  of  the 
cilia.  Whatever  delays  the  ovum  in 
transit,  permitting  it  to  put  out  the 
anchoring  villi,  in  the  presence  of 
a  suitable  soil,  renders  imminent 
the  occurrence  of  an  extra-uterine 
gestation. 


Forty-one  cases  of  bilateral  tubal 
pregnancy  found  on  record  to  which 
the  writers  add  a  case  in  which  there 
was  a  twin  pregnancy  in  one  tube  and 
a  simultaneous  single  pregnancy  in  the 
other.  The  size  of  the  three  3-months 
fetuses  proved  that  the  pregnancies 
were  practically  simultaneous.  In  only 
15  cases  on  record  was  the  tubal  preg- 
nancy simultaneous  on  both  sides.  P. 
Launay  and  Seguinot  (Revue  de  Chir- 
urgie,  April,  1911). 

As  to  the  nature  of  the  soil  required 
by  the  ovum  we  are  not  so  certain. 
Concerning  the  influence  of  delay 
which  is  governed  by  mechanical 
causes  everyone  is  agreed. 

These  causes  may  be  classified 
as : — 

1.  Malformation:  as  diverticula, 
accessory  ostia,  and  persistence  of  the 
greatly  convoluted  fetal  contour  of 
the  tubes. 

2.  Obstruction  from  within :  as  in 
tubal  polypi  and  torsion  of  the  tube. 

3.  Obstruction  from  without :  as  in 
myoma  and  peritoneal  bands  and 
adhesions. 

4.  Inflammation,  which  acts  by  de- 
stroying the  motor  power  of  cilia  and 
musculature  and  secondarily  by  the 
formation  of  different  types  of  ob- 
struction. 

5.  Excessive  size  of  the  ovum  itself, 
as  in  the  delay  which  occurs  in 
external  migration  of  the  ovum. 

The  importance  of  the  inflamma- 
tory factor  in  the  etiology  of  ectopic 
gestation  is  becoming  more  and  more 
appreciated  and  is  even  of  use  in  the 
diagnosis,  a  history  indicating  more 
or  less  pronounced  salpingitis  tending 
to  arouse  our  suspicions  of  the  greater 
possibility  of  an  extra-uterine  preg- 
nancy in  a  doubtful  case. 

An  analysis  of  170  cases  in  the 
author's  cJinic  showed  that  tubal  preg- 
nancy sometimes  results  from  an  infan- 


ABORTION,    TUBAL    (DEzWER). 


191 


tile  condition  of  spiral  torsion  of  the 
tubes,  but  chiefly  from  residues  of  old 
gonorrheal  or  inflammatory  puerperal 
processes.  In  the  diagnosis  inflamma- 
tory conditions  may  be  differentiated 
from  ectopic  gestation  by  the  leucocyte 
count  and  by  puncture  of  the  posterior 
vaginal  wall.  Fehling  (Arch.  f.  Gynak., 
Bd.  92,  Hft.  1,  1911). 

According  to  the  site  of  Implanta- 
tion we  recognize  several  varieties  : — ■ 

.1.  The  interstitial,  located  in  that 
part  of  the  tube  which  pierces  the 
uterine  wall. 

2.  The  isthmial. 

3.  The  ampullar. 

4.  The  infundibular. 

5.  The  ovarian. 

These  are  the  primary  forms. 
Later  the  gestation  sac  by  reason  of 
rupture  or  growth  may  change  its 
position,  giving  rise  to  the  secondary 
forms. 

Thus  the  interstitial  form  may  be 
converted  into  an  intra-uterine  by 
rupture  into  the  cavity  of  the  uterus, 
into  an  abdominal  by  rupture  into  the 
general  cavity  or  into  an  intraliga- 
mentary  by  escape  between  the  layers 
of  the  broad  ligament.  The  isthmial 
and  ampullar  forms  similarly  may 
become  tuboabdominal,  tubo-ovarian, 
abdominal  or  intraligamentary.  An 
infundibular  or  ovarian  pregnancy 
always  tends  to  become  abdominal. 
The  last-named  condition  is  one  of 
the  greatest  curiosities  of  abdominal 
pathology.  All  the  undoubted  cases 
of  ovarian  pregnancy  so  far  observed 
can  be  numbered  on  the  fingers.  The 
interstitial  and  infundibular  forms  are 
almost  as  great  rarities ;  so  that  for 
practical  purposes  we  have  to  do  only 
with  cases  primarily  isthmial  or 
ampullar,  of  which  the  latter  are  most 
numerous,  and  with  the  forms  second- 
ary to  these  primary  varieties. 


Case  of  extra-uterine  pregnancy  in 
which  the  fetus  was  discharged  by  the 
rectum.  Notwithstanding  a  pelvic  ab- 
scess, an  intestinovaginal  fistula,  gen- 
eral adhesive  peritonitis,  and  phlebitis 
of  both  legs,  the  case  ended  in  recovery. 
J.  R.  Laughlin  (Jour.  Amer.  Med. 
Assoc,  May  21,  1910). 

Extra-uterine  pregnancy  assumes 
pathological  significance  when  it  under- 
goes ectopic  attachment.  The  tubal 
ovum  has  a  parasitic  action,  malignant 
in  that  it  destroys  maternal  tissues;  it 
embeds  itself  in  the  tube  wall,  and 
tends  to  the  death  of  the  mother.  The 
growth  of  the  ovum  or  the  enlarge- 
ment of  the  dead  ovum  mass,  thinning 
and  destroying  the  tube  wall,  leads  to 
■  almost  certain  rupture  of  the  tube. 
Primary  rupture  may  be  partial  or 
complete  and  fatal.  If  incomplete,  sub- 
sequent ruptures  will  be  almost  certain 
to  follow.  With  rupture  free  hemor- 
rhage occurs,  which  may  prove  fatal. 
There  may  be  one  rapid  fatal  hemor- 
rhage or  a  series  of  minor  hemor- 
rhages. .  If  death  does  not  occur  from 
hemorrhage,  the  blood  and  the  ovum 
in  the  abdominal  cavity  may  act  as 
imitating  foreign  substances  which  lead 
to  loss  of  function  and  pathological 
changes  in  the  viscera,  to  local  or  gen- 
eral infection,  thrombosis,  embolism, 
etc.  The  dead  ovum  is  almost  as  harm- 
ful as  the  living  one,  from  the  stand- 
point of  rupture,  and  may  be  more 
harmful  as  a  focus  of  infection.  C.  W. 
Barrett  (Amer.  Jour,  of  Obstet,  June, 
1911). 

The  natural  outcome  of  extra-uter- 
ine pregnancy,  as  stated  in  the  defini- 
tion, is  early  interruption,  whether  by 
reasons  of  insufficient  blood  supply 
or  unfavorable  mechanical  conditions 
for  the  continued  development  of  the 
fetus. 

The  most  common  event  is  the 
formation  of  a  tubal  mole  from  the 
slow  leakage  of  blood  about  the  sac. 
This  soon  results  in  the  death  of  the 
fetus  and  cessation  of  growth.  In 
this  way  spontaneous  recovery  may 


192 


ABORTION,    TUBAL    (DEAVER). 


occur.  I  have  several  times  in  the 
course  of  pelvic  operations  encoun- 
tered old  tubal  hematomata  which 
Avere  clearly  the  result  of  a  pre- 
vious tubal  pregnancy  which  had 
terminated  itself  and  retrogressed 
without  giving  the  patient  any  great 
inconvenience.  That  this  is  not  a 
frequent  occurrence  our  clinical  ex- 
perience and  the  infrequency  of  such 
operative  findings  testify.  There  is 
evidence  to  show  that  even  after  the 
death  of  the  fetus  the  chorionic  villi 
may  continue  to  grow  and  exert  an 
erosive  action  on  the  wall  of  the  tube 
which,  coupled  with  the  distention 
due  to  hemorrhage,  may  bring  about 
a  rupture.  More  common  than  this 
is  the  gradual  extrusion  of  the  mole 
from  the  fimbriated  extremity,  a 
process  known  as  tubal  abortion. 
Rupture  of  the  tube  and  tubal  abor- 
tion may  take  place  rapidly  without 
the  previous  formation  of  a  mole. 
These  are  apt  to  be  the  fulminating 
cases. 

Hemorrhage  is  more  free  in  case  of 
rupture  than  in  abortion  as  a  rule : 
more  free  in  rupture  into  the  general 
abdominal  cavity  than  in  rupture  into 
the  broad  ligament,  more  free  when 
the  site  of  rupture  involves  the  pla- 
cental attachment,  and  more  free  at 
the  cornual  end  of  the  tube  than  at 
the  ampullar  end. 

[This  latter  tendency  was  tersely  expressed 
by  Formad,  who  used  to  say,  "Ruptured 
cornual  cases  belong  to  the  coroner ;  rup- 
tured ampullar  to  the  surgeon."  Surgery  in 
its  march  has  modified  this  statement,  but  it 
still  serves  to  point  out  the  relative  dangers. 
John  B.  Deaver.] 

Hemorrhage  is  the  outcome  of 
extra-uterine  pregnancy  which  chiefly 
concerns  us  from  a  practical  stand- 
point.    It  is  probable  that  no  case  of 


ectopic  gestation  occurs  which  is  not 
accompanied  by  hemorrhage  at  some 
time.  It  may,  however,  be  early  or 
late,  slow  or  rapid,  slight  in  amount 
or  profuse.  It  is  the  chief,  though 
not  the  only,  factor  in  the  production 
of  so-called  shock,  and  is  the  main 
agent  in  a  fatal  outcome.  I  shall 
have  more  to  say  concerning  hemor- 
rhage under  the  question  of  treat- 
ment. 

If  the  patient  be  fortunate  enough 
to  survive  the  primary  rupture  and 
the  fetus  live,  she  still  has  to  face  the 
possibility  of  a  second  rupture  of  the 
gestation  sac  in  its  new  position. 
Occasionally  an  extra-uterine  preg- 
nancy may  progress  to  term.  Usually 
this  is  rendered  possible  by  the  escape 
of  the  fetus  within  its  amniotic  sac 
into  the  general  abdominal  cavity, 
the  placenta  remaining  attached  at 
the  primary  site.  In  this  event,  after 
a  spurious  labor  at  term,  the  fetus 
dies  and  offers  an  inviting  site  for  in- 
fection. 

[Operation  is  here  indicated  on  the  same 
principle  as  in  the  case  of  any  foreign  body 
which  threatens  the  host.  This  holds  true  in 
spite  of  the  well-known  fact  that  in  some 
instances  the  fetus  has  caused  little  harrti, 
being  converted  into  a  lithopedion  or  adi- 
pocere.  Such  a  late  terminal  event  presup- 
poses a  series  of  diagnostic  failures  which 
we  trust,  now  that  the  condition  is  so  well 
known  and  understood,  may  not  come  to 
pass.     John  B.  Deaver.] 

TREATMENT.— This  involves  a 
discussion  of  the  immediate  consider- 
ations concerning  an  active  versus 
expectant  mode  of  treatment  in  cases 
of  rupture. 

[It  has  long  been  my  practice  to  operate 
every  acute  case  of  extra-uterine  pregnancy 
without  delay  and  my  results  have  been  so 
uniformly  good  that  it  would  never  have 
occurred  to  me  to  reopen  the  question. 
Robb,   in   1907,   came   forward  with  the   as- 


ABORTION,    TUBAL    (DEAVER). 


193 


sertion  that  surgeons  were  losing  many  of 
their  desperate  cases  from  ovcrhastc  in 
operating  during  shock.  He  believes  that 
shock  is  mainly  due  to  the  elTect  of  the  acci- 
dent of  rupture  upon  the  nervous  system, 
that  it  would  be  a  great  rarity  for  a  patient 
to  bleed  to  death  and  that  cases  in  which  the 
loss  of  blood  in  itself  would  be  sufficient 
to  bring  about  a  fatal  termination  would 
seldom  be  seen  in  time  to  save  the  patient. 
He  bolsters  his  position  by  animal  experi- 
ments, having  observed  that  dogs  do  not  die 
of  hemorrhage  even  after  section  of  the 
uterine  and  ovarian  vessels. 

Just  what  he  considers  the  cause  of  death 
in  these  cases  is  not  clear.  The  coroner's 
statistics  of  Dr.  Formad,  though  he  admits 
that  it  is  on  record  that  in  certain  instances 
the  amount  of  blood  which  was  found  was 
enough  to  fill  the  abdominal  cavity,  Robb 
dismisses  by  saying  that  "such  statements 
are  entirely  too  meager  to  give  us  any  def- 
inite knowledge,  nor  can  they  be  entirely 
depended  on."  He  also  says  in 'this  regard 
that  "in  a  given  fatal  case  it  must  also  be 
proven  that  there  were  no  other  and  possibly 
equally  important  factors  in  the  causation  of 
the  fatal  result."  He  not  only  doubts  that 
the  coroner  saw  the  blood,  but  he  invites  us 
to  prove  that  the  patient  did  not  die  of  cere- 
bral apoplexy  instead  of  abdominal  hemor- 
rhage. As  for  the  animal  experiments  I  can 
only  say  that,  if  he  has  not  seen  a  woman 
die  from  hemorrhage  from  a  uterine  artery, 
he  has  been  more  fortunate  than  I  have  been, 
and  that  I  therefore  still  resort  to  the  old- 
fashioned  expedient  of  tying  as  secure  a 
knot  about  that  vessel  as  I  am  able.  John 
B.  Deaver.] 

Formerly  it  was  not  such  an  un- 
common thing  for  these  patients  to 
bleed  to  death.  Of  the  500  cases 
reported  by  Parry  there  were  336 
deaths,  174  of  which  were  from 
rupture  and  hemorrhage.  Of  113  of 
these  in  which  the  time  of  death  was 
stated  81  had  died  at  the  end  of  24 
hours  and  at  the  end  of  48  hours  only 
15  were  left  alive. 

Of  course  this  gives  a  greatly  ex- 
aggerated idea  of  the  danger  because 
in  those  days  only  the  evident  and 


severe  cases  were  noted.  Still  it 
serves  to  show  that,  without  opera- 
tion, death,  which  was  shown  by 
autopsy  to  be  associated  with  exces- 
sive hemorrhage,  was  not  so  un- 
common a  sequel  If  these  deaths 
were  not  due  to  hemorrhage,  what 
did  cause  them? 

[Has  anyone  seen  a  death  from  shock  of 
rupture  with  an. insignificant  or  even  a  mod- 
erate amount  of  blood  in  the  peritoneal  cav- 
ity? In  the  cases  which  I  have  seen  in  this 
so-called  state  of  shock,  the  condition  of  the 
patient  bore  a  striking  parallelism  with  the 
amount  of  blood  found  in  the  abdominal 
cavity.  I  wish  to  enter  a  strong  protest 
against  the  loose  use  of  the  term  shock  in 
this  condition  as  well  as  the  vicious  tendency 
of  such  flashy  phrases  as  "adding  shock  to 
shock.     John  B.  Deaver.] 

The  great  danger  in  these  cases 
is  not  from  the  shock  of  rupture, 
but  from  the  subsequent  hemorrhage. 
Or,  to  be  very  conservative,  severe 
hemorrhage  is  necessary  to  produce 
the  fatal  outcome.  Let  us  consider 
for  a  moment  this  factor,  shock.  It 
is  known  that  any  acute  lesion  of  the 
peritoneum  produces,  through  shock 
to  the  great  abdominal  nerve  centers, 
a  certain  train  of  symptoms,  whether 
the  lesion  be  due  to  rupture  of  the 
appendix,  twisted  pedicle  of  an  ova- 
rian tumor,  passage  of  gall-stones, 
acute  strangulation  of  the  intestine, 
or  rupture  of  an  extra-uterine  preg- 
nancy, and  to  this  train  of  symptoms 
Giibler  has  given  the  name  "perito- 
nism." These  symptoms  are  inde- 
pendent of  inflammation  or  of  septic 
intoxication.  They  are :  pain,  pro- 
found exhaustion,  distressful  anxiety, 
pallor ;  soft,  quick  pulse  ;  cold  extremi- 
ties, shallow  respiration,  nausea  and 
vomiting.  These  vary  In  degree  and 
are  common  in  some  degree  to  all 
cases  in  which  there  has  been  a  wide 

-13 


194 


ABORTION,    TUBAL    (DEAVER). 


and  abrupt  impression  upon  the  nerve 
centers  of  the  abdomen.  This  is  the 
train  of  symptoms  which  follow  im- 
mediately upon  an  acute  rupture  of 
the  gestation  sac  and  gives  the  picture 
properly  denominated  as  shock.  This 
shock  as  such  is  practically  never 
fatal.  Clinical  evidence  is  conclusive 
on  this  point.  We  do  not  find  our 
patients  dropping  over  dead  from 
acute  strangulation,  twisted  pedicles 
or  tubal  ruptures.  The  shock  exerts 
its  maximum  influence  at  the  moment 
of  the  tearing  injury  to  the  perito- 
neum and  sympathetic  trunks  and 
practically  ceases  at  once  with  the 
release  of  tension  after  the  laceration 
has  been  effected.  This  factor  is 
sudden,  momentary,  expends  its 
energy  and  ceases.  Reaction  begins, 
or  would  begin  at  once,  either  spon- 
taneously or  with  the  aid  of  stimu- 
lants. This  sudden  insult  to  the 
peritoneum  and  the  great  sympathetic 
centers  is  not  what  places  the  patient's 
life  in  jeopardy  and  holds  her  hover- 
ing in  the  balance  for  hours. 

This  is  but  the  advance  agent  of 
the  real  executioner,  hemorrhage. 
Read  in  the  same  order  as  before, 
leaving  off  the  pain  in  the  beginning, 
we  have  in  the  symptoms  of  shock  the 
symptomatology  of  hemorrhage  :  Pro- 
found exhaustion,  distressful  anxiety, 
pallor;  soft,  quick  pulse;  cold  extrem- 
ities, shallow  respiration,  air  hunger, 
nausea  and  vomiting. 

[Who  is  that  man  who  will  tell  us  in  these 
cases  where  shock  leaves  off  and  hemor- 
rhage begins  to  play  the  leading  role  ?  I  feel 
most  strongly  that  we  are  dealing  here  with 
a  wrong  use  of  words,  that  there  is  a 
sophistical  "nigger  in  the  woodpile."  I  do 
not  believe  that  the  patients  reported  by  the 
advocates  of  the  expectant  treatment  as  suf- 
fering from  shock  were  suft'ering  from  pri- 
mary   shock,    but    instead    from    shock    plus 


hemorrhage,  and  that,  by  the  time  they  were 
seen  by  the  surgeon,  that  hemorrhage  was 
playing  by  far  the  chief  role.  Those  patients 
who  are  fortunate  enough  to  lose  but  a 
small  quantity  of  blood  at  the  time  of  rup- 
ture react  from  the  shock  with  considerable 
promptitude.  By  the  time  proper  surgical 
intervention  can  be  brought  to  bear,  their 
condition  is  such  as  to  give  the  surgeon  little 
immediate  anxiety  as  far  as  the  shock  of 
operation  is  concerned.  These  patients 
should  be  operated  at  once  on  account  of 
the  danger  of  secondary  rupture  or  a  re- 
newal of  bleeding.  They  should  all  get  well. 
John  B.  Deaveu,] 

An  immediate  operation  detracts 
nothing  from  the  chances,  but  guards 
against  imminent  danger.  Those 
patients  who,  when  seen  an  hour  or 
several  hours  after  rupture  (I  am 
speaking  of  conditions  as  we  find 
them,  for. patients  do  not  come  to  a 
hospital  or  doctor's  office  to  be  handy 
at  the  time  of  rupture),  are  hanging 
in  the  balance  with  the  symptoms 
some  are  pleased  to  call  shock  are 
not  suffering  from  shock,  but  rather 
of  shock  plus  hemorrhage,  shock  in 
small  type,  hemorrhage  in  large  red 
capitals,  and  the  examples  of  reaction 
are  not  proofs  of  the  wisdom  of  wait- 
ing, but  of  the  fact  that  many  desper- 
ate cases  will  stop  just  short  of  bleed- 
ing to  death  if  left  to  themselves,  a 
fact  which  has  for  years  been  patent 
to  all. 

The  necessity  for  surgical  interfer- 
ence lies  in  the  fact  that  one  can  never 
foretell  the  result  if  a  case  is  left  to 
nature.  Tubal  abortion  usually  oc- 
curs before  the  sixth  week  of  impreg- 
nation, pregnancy  being  usually  ar- 
rested thereby.  H.  C.  Coe  (Annals  of 
Gynec.  and  Ped.,  Jan.,  1906). 

There    are    certain    factors    which 

would  favor  the  cessation  of  bleeding, 
such  as  a  long  and  voluminous  sig- 
moid or  omentum  wedging  down  in 
the  pelvis,  butj  as  we  are  not  often 


ABORTION,    TUBAL    (DEAVER). 


195 


furnished  with  a  diagram  of  interior 
arrangements  in  these  cases,  we  do 
not  know  whetlicr  these  stanch  allies 
are  on  the  ground.  The  character  of 
the  rent  and  the  coagulability  of  the 
blood  we  cannot  estimate. 

[As  sure  as  there  are  immutable  laws  of 
hydrostatics  and  of  the  circulation  of  the 
blood,  these  patients  have  died  in  the  past  in 
considerable  numbers  from  hemorrhage  and 
occasional!}^  die  today  from  that  cause,  and 
the  only  reason  more  do  not  die  of  it  is  be- 
cause of  the  early  operation  practised  by 
clinical  surgeons. 

I  am  willing  to  grant  that  a  patient  should 
not  have  a  "penknife"  operation  done  on  her 
before  she  has  recovered  from  her  first  faint. 
There  is  reason  in  all  things.  It  is  equally 
true  that  a  patient  in  articnlo  mortis  should 
not  be  subjected  to  operation.  "The  re- 
sources of  surgery  are  rarely  successful 
when  practised  on  the  dying.  These  princi- 
ples, however,  should  not  be  made  use  of 
to  attack  a  mode  of  treatment  which  has 
been  crowned  with  the  highest  success. 
John  B.  Deavee.] 

The  quicker  a  woman  with  ectopic 
gestation  is  operated  upon,  the  better 
are  her  chances  for  recovery.  Further- 
more with  few  exceptions,  the  opera- 
tions should  be  done  by  the  abdominal 
route,  and  the  element  of  time  be  con- 
sidered as  important.  A  quick  oper- 
ator's patients  have  a  better  chance  than 
have  those  of  a  slow  operator.  A  care- 
ful peritoneal  toilet  is  not  desirable ;  re- 
move the  large  blood-clots  that  are 
readily  accessible  and  close  the  abdomen 
without  drainage.  H.  J.  Boldt  (Mo. 
Cyclo.,  April,  1908). 

The  pathology  of  the  condition  shows 
that  treatment  directed  toward  the  kill- 
ing of  the  ovum  is  irrational.  Patients 
in  good  condition,  with  or  without  rup- 
ture, are  almost  certain  to  have  future 
trouble,  and  should  be  operated  upon  as 
soon  as  possible.  Patients  in  bad  con- 
dition, with  concealed  hemorrhage, 
show  collapse  according  to  the  loss  of 
blood,  and  rational  treatment  should 
aim  to  stop  further  hemorrhage.  Open- 
ing the  abdomen  and  ligating  the  proper 
vessels   is  the  only   way  to   effectively 


control  internal  hemorrhage,  and  when 
done  rapidly  and  carefully  does  not  tax 
the  patient  severely.  Universal  clinical 
experience  and  study  of  the  pathology 
of  this  condition  show  the  danger  of 
delay.  While  the  patient  is  living,  the 
more  desperate  the  case,  the  greater  the 
need  of  immediate  action.  C.  W.  Bar- 
rett (Amer.  Jour,  of  Obstet.,  June, 
1911). 

My  position  then  is  this :  A  con- 
tinuance of  the  collapsed  condition, 
commonly,  and  as  I  believe  erron- 
eously, termed  shock,  for  a  longer 
time  than  one  hour  indicates  that 
a  considerable  hemorrhage  has  oc- 
curred and  may  be  continuing'.  The 
surgical  indications  are  clear — stop 
the  bleeding-;  stimulate.  Let  us  not 
revert  to  the  dark  ages  in  the  ranks 
of  those  who  "watched  the  life  ebb 
rapidly  from  the  pale  victim  of  this 
accident,  but  never  raised  a  hand  to 
help  her." 

According  to  Schauta,  the  maternal 
mortality  in  non-operative  cases  is  68.8 
per  -cent.  The  writer  is  inclined  to  feel 
that  this  percentage  is  too  high,  that 
more  cases  of  ectopic  gestation  escape 
recognition  and  live  than  we  have  sus- 
pected. At  the  Columbus  Hospital  op- 
eration is  always  resorted  to,  and,  per- 
formed speedily  and  promptly,  should 
not  give  a  mortality  of  over  2  per  cent. 
The  dangers  are  from  shock,  hemor- 
rhage, sepsis,  exhaustion,  and  intestinal 
obstruction.  J.  M.  Keyes  (N.  Y.  Med. 
Jour.,  Aug.  6,  1910). 

Since  1900  I  have  had  110  cases 
of  extra-uterine  pregnancy,  many  of 
them  of  the  acute  type,  without  a 
death. 

My  procedure  in  these  urgent  cases 
is  as  follows :  If  the  condition  be 
very  low,  stimulation  is  begun  on 
admission  by  hypodermoclysis  and 
strychnine.  If  there  is  extreme  rest- 
lessness, morphine  is  a  valuable  ad- 
junct. 


196 


ABORTION,   TUBAL    (DEAVER). 


They  are  placed  on  the  table  with 
as  little  disturbance  as  possible  and  a 
light  quick  etherization  given.  Prep- 
aration is  rapidly  completed  and 
intravenous  transfusion  of  normal 
saline  solution  started  as  the  abdom- 
inal incision  is  made.  "Get  in  quickly, 
get  out  quicker"  applies  here  as  forci- 
bly as  anywhere  in  surgery.  The 
offending  tube  and  ovary  are  re- 
moved. The  clots  are  scooped  out, 
and,  if  the  condition  of  the  patient 
warrants,  the  abdomen  is  flushed  out 
and  filled  with  normal  saline  before 
closure. 

In  70  cases  of  extra-uterine  pregnancy 
encountered  by  the  writer  the  fetus  was 
found  behind  the  uterus  e'ght  times, 
four  times  in  the  tube,  in  1  partly  in 
the  tube  and  partly  in  a  sac,  in  2  in  a 
small  sac  near  the  tube,  once  in  a  cavity 
formed  by  the  tube  and  ovary,  once  on 
top  of  the  bladder,  and  once  on  top  of 
the  uterus.  In  13  it  was  found  in 
the  lower  part  of  the  abdominal  cavity. 
In  two  instances  the  fetal  structures 
were  apparently  safely  implanted  among 
loops  of  intestine.  In  one  of  these  a 
living  4-nionths  fetus  was  found.  In 
this  instance  the  history  did  not  clearly 
determine  the  date  of  expulsion  from 
the  ruptured  tubs.  The  routes  em- 
ployed for  operation  in  his  series  were 
the  abdominal  fifty  times,  the  vaginal 
nine,  and  the  vaginal  immediately  fol- 
lowed by  the  abdominal  or  vice  versa 
eleven  times.  Bovee  (Amer.  Jour,  of 
Obstet.,  April,  1910). 

I  have  frequently  seen  the  patient 
go  off  the  table  with  a  far  stronger 
pulse  and  in  better  condition  than 
before  the  operation,  a  sufficient  ref- 
utation of  the  charge  of  "adding 
shock  to  shock."  I  have  rather  re- 
fused to  allow  hemorrhage  to  be 
added  to  hemorrhage,  and  now  I  am 
not  afraid  to  fill  her  vessels  with  suffi- 
cient fluid  to  satisfy  the  mechanical 
needs  of  the  circulation. 


[My  last  case  before  this  article  was  writ- 
ten happened  to  be  most  appropriate  to  this 
discussion  :  A  young  won)an,  aged  24,  mar- 
ried three  years,  with  nothing  of  note  in  her 
past  history.  She  had  had  one  child  nine 
months  ago,  which  died  in  January.  No 
miscarriages.  Menstruation  had  always  been 
regular  and  norm.al  up  to  her  January 
period,  which  she  missed.  At  the  February 
period  she  bled  quite  profusely  and  for  a 
longer  time  than  usual.     No  staining  since. 

Suddenly  at  6  a.m.  on  February  12th,  dur- 
ing coitus,  she  had  an  acute  pain  in  the  lower 
left  side  of  the  abdomen,  followed  in  a  few 
minutes  by  syncope.  Soon  she  recovered, 
but  fainted  several  times  in  the  course  of  the 
morning,  and  vomited  several  times.  Grad- 
ually grew  weaker  and  grew  short  of  breath. 
On  examination  she  did  not  have  a  particle 
of  color  in  her  skin  or  lips.  Expression  was 
anxious :  she  was  restless  and  dyspneic. 
The  pulse  was  about  180  and  barely  per- 
ceptible. Her  abdomen  was  moderately  dis- 
tended and  tender  in  left  side  low  down. 
Vaginal  examination  was  negative  except  for 
tenderness  in  the  left  lateral  fornix. 

She  was  taken  to  the  operating  room  and 
subcutaneous  infusion  started  with  the  ether. 
Preparation  having  been  quickly  accom- 
plished, the  operation  and  intravenous  trans- 
fusion were  started  together.  A  left-sided 
tubal  pregnancy  (see  colored  plate)  the  size 
of  a  hickory  nut  was  found  in  the  isthmial 
portion  about  2  cm.  from  the  cornual  ex- 
tremity. ■  Through  the  tube  was  a  perfora- 
tion only  about  as  large  as  a  pinhead.  No 
time  was  wasted  in  determining  whether 
there  was  any  active  bleeding.  Tube  and 
ovary  were  removed.  As  the  patient's  con- 
dition was  improving  on  the  table,  I  washed 
out  the  blood,  of  which  there  was  a  large 
quantity,  and  filled  the  abdomen  before  clos- 
ure with  salt  solution. 

Her  pulse,  which  before  the  operation  was 
180,  at  the  end  of  the  operation  was  140  and 
much  improved  in  quality.  She  was  put  back 
in  bed  and  continuous  proctoclysis  started. 
John  B.  Deaver.] 

I  wish  to  call  attention  to  the  value 
or  rather  necessity  of  filling  the 
empty  blood-vessels  with  saline  in 
these  depleted  cases.  In  the  above 
case,  the  amounts  used  were  as  fol- 
lows :      By    hypodermoclysis    at    the 


cr 


ABSCESS    (WITHERSTINE). 


197 


beg-inning-,  1000  c.c.  Intravenous 
transfusion  during;  the  operation  2000 
c.c.  Left  in  the  abdomen  at  least 
1500  c.c.  Then  in  the  twelve  hours 
after  operation  her  thirsty  vessels 
absorbed  by  way  of  the  large  bowel 
4000  c.c.  additional.  Nearly  nine 
liters  of  saline,  over  two  gallons  of 
fluid  to  meet  the  mechanical  needs  of 
the  circulation.  AMthout  this  saline 
my  patient  would  have  run  grave 
danger  of  dying  on  the  table.  As  the 
intra-abdominal  pressure  is  released 
by  incision  the  blood  flows  into  the 
"splanchnic  tank"  and  from  the  great 
depletion  due  to  hemorrhage  nothing 
is  left  in  the  great  vessels  for  the 
heart  to  pump.  The  medullary 
vessels  are  asphyxiated  and  death 
results.  This  restoration  of  the  fluid 
volume  of  the  blood  is  a  most  impor- 
tant point  and  will  eliminate  what  is 
I  suspect,  the  most  potent  factor  in 
that  additional  shock  so  feared  by  the 
misguided  advocates  of  expectancy. 

It  is  now  universally  agreed  that  dur- 
ing active  hemorrhage  consequent  on 
tubal  rupture  or  abortion  the  correct 
treatment  is  to  open  the  abdomen  and 
remove  the  gestation  sac.  In  the 
writer's  series  of  cases  this  was  done  in 
16.  In  2  of  these  the  patients  when 
seen  were  collapsed  and  almost  pulse- 
less. Their  condition  warranted  only 
slight  anesthesia,  and  after  removing 
the  ruptured  tube  the  abdomen  was 
closed  without  any  attempt  to  clear  out 
the  blood-clot  which  filled  the  abdomen. 
From  the  writer's  experience  in  these 
cases  immediate  operation,  even  in  the 
collapsed  condition  of  the  patient,  is 
better  than  temporizing  with  saline 
infusion  in  the  hope  of  improving  the 
condition  of  the  pulse  before  operating. 
The  best  way  to  improve  the  pulse  is 
first  to  open  the  abdomen  and  remove 
the  source  of  bleeding,  and  then  admin- 
ister salines.  In  14  cases  so  treated  the 
condition  of  the  patient  permitted  of 
the    delay    necessary    for    preparatory 


treatment  and   for  the   removal  of  all 

blood-clots  from  the  abdomen.     Kynoch 
(Lancet,  June  10,  1911). 

John  B.  Deaver, 

Philadelphia. 

ABSCESS.— DEFINITION.— A 

circumscribed  collection  of  pus  in  an 
adventitious  cavity,  the  result  of  local- 
ized inflammation  due  to  infection  by 
pus-forming  microbes,  differing  from 
diffuse  suppuration  which  is  not  cir- 
cumscribed and  from  purulent  effusion 
or  empyema  which  is  found  in  a  natural 
or  pre-existing  cavity,  as  the  pleura, 
pericardium,  mastoid  cells,  etc. 

VARIETIES.— An  abscess  may  be 
acute,  or  zvarm,  when  due  to  pus- 
microbes  only:  staphylococci,  strepto- 
cocci, and  others  ;  chronic,  or  cold,  when 
due  to  a  specific  microbe,  especially 
that  of  tuberculosis. 

Abscesses  have  been  classified  ac- 
cording to : — 

1.  Etiology.  —  Atheromatous,  em- 
bolic, fecal  (stercoraceous),  metastatic, 
miliary,  ossifluent,  puerperal,  pyemic, 
residual,  symptomatic  or  congestive, 
tropical,  tubercular  (strumous,  lym- 
phatic, or  scrofulous),  etc.. 

2.  Pathology.  —  Acute  or  warm, 
canalicular,  caseous,  chronic  or  cold, 
critical,  gangrenous  (anthrax),  lig- 
neous, perforating,  phlegmonous,  etc. 

3.  Location  (Organ  or  Tissue  In- 
volved).— Alveolar  (gum,  jaw,  teeth), 
of  axilla,  bone  (subperiosteal),  brain 
(cerebral,  cerebellar),  bursal,  corneal 
(hypopyon),  deep,  dorsal,  follicular, 
hepatic,  of  hip-joint,  iliac,  ischiorectal, 
lacunar,  lumbar,  mammary  (milk,  weid 
or  weed,  breast),  marginal,  mediastinal, 
meningeal  (extradural,  subdural),  of 
neck,  nephritic  and  perinephritic,  of 
nose,  of  palate,  palmar,  of  pancreas, 
perityphlitic,  popliteal,  of  prostate, 
psoas,   rectal,  retropharyngeal,  of  skin 


198 


ABSCESS    (WITHERSTINE). 


(furunculosis),  of  scalp,  of  space  of 
Retzius  ( preperitoneal  cavity),  spinal 
or  vertebral,  of  spleen,  superficial, 
thecal,  urethral  and  periurethral,  vulvo- 
vaginal (Bartholinian ),  etc.  All  the 
above  varieties  will  be  considered  under 
their  respective  anatomical  heads. 

ACUTE,  OR  WARM.— Symptoms. 
— An  acute  abscess  may  be  either  su- 
perficial or  deep.  When  it  is  superficial 
the  local  symptoms  predominate ;  when 
it  is  deep  the  general  symptoms  are 
more  marked. 

The  pain,  due  to  compression  of  the 
nerves  by  the  disturbed  tissues,  varies 
in  degree  with  the  density  of  the  parts 
involved,  the  local  supply  of  sensitive 
nerves,  and  the  tension  produced  by  the 
inflammatory  products.  In  superficial 
abscess  the  pain  is  generally  localized 
in  the  center  of  the  swelling,  and  is 
sharp  and  lancinating;  in  deep  abscess 
it  is  more  diffuse  and  dull. 

Redness  is  due  to  engorgement  of 
the  local  blood-supply,  and  the  swelling 
to  the  inordinate  distention  of  the  ves- 
sels and  the  secondar}-  escape  of  blood- 
plasma,  colorless  corpuscles,  etc.,  into 
surrounding  tissues.  It  may  become 
very  great  in  certain  regions,  such  as  the 
lids,  the  lips,  etc.,  in  which  the  cellular 
tissue  is  lax.  As  the  purulent  foci  run 
together  and  form  a  single  cavity,  the 
center  of  the  tumefaction  becomes  soft, 
and  darker  in  color,  and  the  abscess  is 
said  to  be  "pointing." 

Edematous  infiltration  in  superficial 
abscess  denotes  the  presence  of  pus ;  in 
deep  abscess  subcellular  edematous  in- 
filtration is  an  important  sign  of  deep 
suppuration. 

Local  heat,  throbbing,  and  tension  are 
mechanical  results  of  the  causes  of  tu- 
mefaction tending  to  decrease  as  the 
formation  of  pus  progresses. 

Hyperpyrexia  is  in  relation  with  the 


location  of  the  abscess,  the  ease  with 
which  the  pus-microbes  can  enter  the 
circulation,  and  the  amount  of  pus  and 
necrotic  tissues  present.  In  superficial 
abscess  there  is  but  little  rise  of  tem- 
perature, but  in  deep  abscesses  it  some- 
times reaches  104°  F.  (40°  C.)  at  the 
time  the  wall  of  granulation  tissue  is 
established.  A  remission  of  about  one 
degree  each  morning  usually  takes 
place.  When  the  pus  has  found  an 
issue,  or  has  become  completely  sur- 
rounded by  the  limiting  membrane,  the 
intensity  of  the  fever  is  usually 
reduced. 

In  a  superficial  abscess,  if  a  chill  oc- 
cur, it  is  usually  very  slight,  and  ap- 
pears between  the  fourth  and  the  eighth 
day.  It  indicates  the  formation  of  pus. 
In  a  deep  abscess  a  chill  generally 
occurs,  lasting  from  a  few  moments  to 
half  an  hour. 

Fluctuation  is  generally  obtained 
when  the  purulent  focus  has  been 
formed.  A  sharp  localized  pain  on 
pressure  over  the  apex  of  the  swelling 
obtained  at  this  time  supports  the  likeli- 
hood that  pus  is  present,  but  fluctua- 
tion is  liable  to  be  a  misleading 
symptom. 

Interference  with  motion  or  the 
normal  functions  of  a  part  is  sometimes 
produced  through  the  proximity  of  an 
abscess. 

In  deep-seated  abscess  any  or  all  of 
the  general  symptoms  of  abscess  may 
be  lacking,  except  loss  of  flesh  and 
strength.  This  is  especially  true  of 
hepatic  or  cerebral  abscess.  The  symp- 
toms usually  present  are  local  tender- 
ness and  pain,  pressure  symptoms, 
overlying  edema,  brawniness,  muscular 
rigidity  and  ankylosis  of  neighboring 
joints,  in  addition  to  the  symptoms  of 
acute  suppuration — fever,  chills,  sweats, 
anorexia,  restlessness,  etc. 


ABSCESS    (WITHERSTINE). 


199 


Etiology. — Inflammation  clue  tc)  trau- 
matisms and  lesions  of  all  kinds,  espe- 
cially the  introduction  of  foreign  bodies 
under  the  epidermis,  are  the  usual 
causes  of  abscess.  While  l)l(nvs  do  not 
apparently  produce  superficial  lesions 
in  the  majority  of  cases,  the  fact 
remains  that  an  invisible  abrasion  may 
be  present  and  serve  as  a  channel  for 
the  introduction  of  the  pyogenic  organ- 
ism. The  cutaneous  glands,  through 
weakened  local  resistance,  may  also 
become  the  transmitting  media.  Any 
cause  removing  the  epithelial  layer  of 
the  mucous  membrane  may  also  form 
the  primary  etiological  factor  of  an 
abscess  in  the  membrane  or  in  the  sub- 
mucous connective  tissue.  Abscesses 
also  arise  in  connection  with  the  various 
septic  fevers. 

The  three  essentials  in  the  formation 
of  an  abscess  are :  pyogenic  organisms 
in  sufficient  numbers  and  virulence,  their 
proper  implantation  within  the  tissues, 
and  a  sufficiently  low  resisting  power, 
either  local  or  general. 

Pathology. — While  several  varieties 
of  micro-organisms  are  found  in  the 
pus  of  an  acute  abscess,  the  principal 
ones  wdiich  ordinarily  cause  purulent 
inflammation  are  the  Staphylococcus 
pyogenes  {aureus  and  albus),  Strepto- 
coccus pyogenes^  Micrococcus  gonor- 
rhocce,  Bacterium  coli  commune,  Bac- 
terium pyocyaneum,  pncumococcus,  and 
the  Sarcina  tetragena.  Less  frequent  in 
the  production  of  suppuration  are  the 
typhoid  bacillus,  the  influenza  bacillus, 
the  diphtheria  bacillus,  the  actinom3^ces, 
etc. 

Suppuration  can  occur  in  man  with- 
out the  presence  of  bacteria.  Both  in 
animals  and  in  man,  suppuration  may- 
be due  to  the  irritation  of  chemicals. 
Investigators  have  shown  that  suppura- 
tion is  only  a  certain  stage  of  inflam- 
mation, not  a  separate  qualitative  form 


of  inflammation.  The  serous  formation 
of  blebs  and  bullae  becomes  purulent 
without  the  presence  of  bacteria.  Karl 
Kreibich  (Wiener  klin.  Woch.,  June 
13,   1901). 

Case  of  subcutaneous  abscesses  due 
to  the  gonococcus  in  a  child  2  years  of 
age.  The  little  patient  developed  an 
acute  anterior  urethritis  and  areas  of 
induration  to  the  left  and  right  of  the 
anus.  All  were  found  to  contain  pus 
in  which  gonococci  were  present.  Ger- 
shel    (Med.  Record,  Feb.  7,  1903). 

Chronic  suppurative  processes  are 
very  frequently  unattended  by  fever, 
while  acute  suppurative  processes  are 
frequently  unattended  by  fever.  In  a 
g^iven  case,  therefore,  the  absence  of 
fever  must  have  little  weight  by  itself 
in  excluding  the  possibility  of  suppu- 
ration. Since  a  rise  of  temperature 
above  100°  F.  occurs  in  about  two- 
thirds  of  all  aseptic  cases,  the  pres- 
ence of  fever  alone  must  have  little 
weight  in  making  a  diagnosis  of  sup- 
puration. Lyman  Allen  (Inter.  Jour, 
of  Surg.,  Feb.,  1905). 

In  the  common  acute  type  of  gland- 
ular  suppuration   in   infancy  and  early 
childhood    suppuration    is    not    diffuse, 
but  more  or  less  limited  by  the  line  of 
the  distended  capsule  of  the  gland.    The 
infection    having    been    brought    under 
control  by  the   sacrifice  of  the  paren- 
chyma  of   the    gland,    nature    seeks    as 
speedily  as  possible  to  evacuate  the  pus 
and    detritus.      Therefore,    in    incising 
such    abscesses    a    destructive    process 
should  not  be  checked  by  heroic  meas- 
ures,  but   the    requisite   amount   of   aid 
just   given  to   complete    a   conservative 
process.       Southworth      (Archives     of 
Pediatrics,    Sept.,    1911). 
Suppuration  is  almost  invariably  pre- 
ceded   by    inflammation     due    to    the 
pyogenic    micro-organisms.      The    first 
effect  of  the  bacterial  toxins  on  the  local 
circulation    is    to    cause    an    increased 
rapidity   of   the   flow   of   blood   in   the 
part,  the  vessels  becoming  engorged  and 
dilated.     This  is  succeeded  by  slowing 
of  the  current  and  passage  through  the 
vascular  walls  and  into  the  surrounding 


200 


ABSCESS    (WITHERSTINE). 


tissues  of  colorless  corpuscles  (leuco- 
cytes), a  few  red  corpuscles,  and  blood- 
plasma,  the  latter  of  which  become 
coagulated  and  finally  softened.  One 
or  several  cavities  are  thus  formed ;  but, 
if  the  cavities  are  multiple,  the  barriers 
usually  soften  and  a  single  focus  is 
established.  The  pus  is  composed  of 
the  corpuscles  which  perish  in  the 
cavity  thus  formed,  the  broken-down 
remains  of  tissue,  and  the  plasma.  At 
a  distance  from  the  location  of  the 
abscess  the  circulation  is  normal,  but, 
as  the  diseased  area  is  approached,  the 
slowing  of  the  blood-current  becomes 
gradually  more  evident,  until  a  zone  of 
living  leucocytes  is  met,  forming  a  pro- 
tective barrier  around  the  abscess 
cavity.  The  surrounding  parts  also 
become  permeated  with  new  vessels, 
and  a  zone  of  granulation  tissue  (the 
pyogenic  membrane  of  older  writers)  is 
formed.  The  spread  of  the  suppuration 
being  thus  checked,  the  pus  is  forced 
to  the  surface  because  it  finds  the  least 
resistance  in  that  direction ;  but,  if  an 
aponeurosis  or  fascia  interfere,  it  bur- 
rows until  an  exit  is  found. 

The  role  of  the  white  corpuscles  (leu- 
cocytes) has  been  interpreted  in  various 
ways;  Cohnheim  considered  them  as 
elements  of  repair;  others  have  attrib- 
uted to  them  the  role  of  scavengers. 
The  accepted  theory  at  present,  how- 
ever, is  that  of  Metchnikoff,  who  con- 
siders them  able  to  attack  and  destroy 
invading  organisms.  The  process  is 
termed  by  him  phagocytosis,  the  cells 
being  called  phagocytes  (^ayw,  to  eat, 
and  KUTos,  a  cell). 

The  dead  leucocytes  in  pus  must  be 
looked  upon  as  the  cells  that  have  been 
brought  up  rapidly  to  interfere  with  the 
spread  or  diffusion  of  the  products  of 
the  micro-organisms ;  a  large  number 
of  these  cells  coming  in  contact  with 


the  poison  in  a  concentrated  form  may 
succumb  to  its  action ;  but  before  doing 
so  they  are  able  to  deal  with  a  certain 
quantity  of  the  poisonous  material, 
breaking  it  down  and  rendering  it  inert. 
Other  cells  are  constantly  being  brought 
up  to  assist  these,  until,  at  length,  the 
bacteria  are  completely  hemmed  in. 
They  live  for  a  short  time  on  the  dead 
tissues ;  but,  being  localized  by  the 
barrier  of  leucocytes,  they  ultimately 
die,  either  from  inanition  or  because 
they  are  poisoned  by  their  own  prod- 
ucts or  by  immunizing  constituents  of 
the  blood-plasma.  It  is  found  very 
frequently  on  opening  an  abscess  that 
no  organisms  can  be  seen,  those  that 
were  originally  present  appearing  to 
have  undergone  degenerative  changes 
and  to  have  been  taken  up  by  the  phag- 
ocytes, or  devouring  cells. 

The  process  includes,  according  to 
Sajous,  participation  of  the  proteolytic 
or  peptonizing  action  of  enzymes  in  the 
serum  supplied  in  large  quantities  to 
the  abscess.  The  prevailing  view  is 
that  these  are  produced  by  the  pyogenic 
bacteria.  From  his  viewpoint  (see 
"Internal  Secretions,"  vol.  ii,  4th  ed., 
1911,  p.  907)  these  ferments  are  se- 
creted (though  originally  derived  from 
the  pancreas,  thyroid,  and  adrenals)  by 
phagocytes  (Metchnikofif's  trypsic  cy- 
tase),  themselves  and  their  hquefying 
action  has  for  its  purpose  to  destroy 
the  bacteria  and  their  toxins  in  the  ab- 
scess. The  pathogenic  organisms  are 
first  sensitized  and  softened  by  opso- 
nins and  agglutinins  (thyroid  secre- 
tion), and  thus  rendered  vulnerable  not 
only  to  the  digestive  action  of  the  phag- 
ocytes when  ingested  by  these  cells,  but 
to  the  ferments  (trypsin  mainly)  they 
contribute  to  the  abscess  fluids,  in  which 
they  accumulate  in  large  numbers. 

Differential     Diagnosis.  —  Fluctua- 


ABSCESS    (WITHERSTINE). 


201 


tion  only  indicating  the  presence  of 
lluitl.  tlie  presence  of  tliis  sign  without 
the  other  symptoms  mentioned  should 
inspire  great  circumspection,  especially 
if  surgical  measures  are  cmpU)yo(l. 

Aneurism  is  the  most  dangerous  con- 
dition to  fear.  It  has,  however,  a  less 
acute  history,  a  peculiar  thrill  and  ex- 
pansile pulsation,  and  can  only  exist  in 
close  proximity  to  a  large  vessel. 

Certain  semisolid  growths  may  sim- 
ulate an  ahscess.  A\'hen  the  possibility 
of  an  aneurism  has  been  eliminated,  a 
fine  trocar  or  exploring  needle,  if  care- 
fully used,  will  determine  the  diagnosis. 

Prognosis. — This  depends  upon  the 
general  health  of  the  patient.  In  the 
robust  a  suppurative  process  usually 
reaches  the  stage  of  resolution  without 
giving  rise  to  complications.  In  indi- 
viduals weakened  by  disease,  hereditary 
or  acquired,  an  abscess  may  be  pro- 
tracted and  exhaustive,  and  diffusion  is 
more  likely  to  occur  if  resisting  tissues 
interfere  with  the  superficial  evacuation 
of  the  pus.  Deep  abscesses  are  espe- 
cially prone  to  become  protracted 
through  this  cause,  the  resistance  of 
muscular  aponeuroses,  etc.,  forcing  the 
pus  into  the  cellular  interstices.  Fistu- 
lous tracts,  or  large  suppurative  areas, 
are  thus  created,  and  the  patient  may 
succumb  to  blood  poisoning  or  asthenia. 

Treatment.  —  General  Measures. — 
Rest  and  elevation  of  the  affected 
region,  if  possible;  salines,  if  purgation 
is  necessary.  Easily  assimilable  food, 
but  not  low  diet;  avoidance  of  stimu- 
lating beverages,  alcohol,  coffee,  etc. 

Internal  Remedies. — If  the  case  is 
seen  early  the  suppuration  can  some- 
times be  arrested  by  the  use  of  one  of 
the  following  agents,  supplemented  by 
one  of  the  local  applications :  Tincture 
of  aconite,  3  to  10  drops  every  hour, 
closely    watching    the    patient's    pulse ; 


tincture  of  veratrum  viride,  1  drop 
every  hour  until  the  pulse  becomes 
slower,  the  skin  moist,  and  slight 
nausea  occurs;  or  calcium  sulphide 
(sulphurated  lime),  Yu)  grain  every 
hour;  or,  again, 

I^  Sulphate  of  quinine,  1  grain. 
E.vt.  of  nux  vomica,  ]/^  grain. 

For  one  pill,  to  be  taken  every  three  hours. 

Many  incipient  abscesses  disappear 
under  the  internal  use  of  the  hypophos- 
phites  of  potassium,  sodium,  and  cal- 
cium. They  also  act  as  an  excellent 
prophylactic,  if  given  before  pus  has 
formed.  Tousey  believes  them  to  be 
more  efficient  than  calcium  sulphide. 
The  combination  used  by  Tousey  is  5 
grains  of  calcium  hypophosphite,  and  2 
grains  each  of  the  sodium  and  potas- 
sium hypophosphites,  administered  in 
syrup  or  two  capsules,  followed  by  half 
a  glassful  of  cold  water. 

Fresh  brewers'  yeast  in  doses  of  oj 
to  oij  in  water  or  undiluted,  just  before 
or  during  meals,  is  a  favorite  remedy 
with  many,  although'  diarrhea  some- 
times results,  even  when  the  yeast  is 
fresh.  A  substitute  preparation  is  made 
by  macerating  compressed  yeast  in 
water.    Desiccated  yeast  is  also  used. 

In  addition  to  these  internal  remedies, 
we  should  not  forget  that  stimulation, 
nutrition  and  general  hygienic  measures 
are  of  considerable  value. 

Thyroid  gland  in  doses  of  1  or  2 
grains  three  times  daily  hastens  the 
disappearance  of  abscesses,  by  increas- 
ing the  proportion  of  opsonins  in  the 
blood  (Sajous). 

The  authors  report  on  the  use  of 
fresh  normal  blood-serum  from  the 
horse  or  from  cattle  in  the  local  treat- 
ment of  acute  suppurative  processes  in 
100  cases.  The  pus  was  first  aspirated, 
serum  next  injected  to  rinse  out  the 
cavity,  using  a  needle  closed  at  the  end, 
but  with  a  row  of  openings  just  above 


202 


ABSCESS    (WITHERSTINE). 


it;   then  the   excess   of   fluid   aspirated, 
and  the  opening  covered  with  a  bit  of 
sterile   gauze   held   by   adhesive.      It   is 
important  that  all  the  excess  of  serum 
be  removed  from  the  cavity ;  otherwise, 
symptoms    of    serum    intoxication    may 
follow.    The  serum  apparently  produces 
both  a  passive  and  an  active  immunity, 
stimulating  leucocytosis  and  phagocyto- 
sis.    Better  healing  can  be  obtained  by 
this  method,  according  to  the  authors, 
than  in  any  other  way.    Acute  abscesses 
in  the  soft  parts,  whatever  be  the  micro- 
organism present,  show  especially  good 
results.     One  treatment  with  the  serum 
generally    suffices.      L.    Fejes    and    E. 
Gergo    (Mitteilungen  aus  den  Grenzge- 
bieten  der  Medizin  und  Chirurgie,  xxiii, 
1911). 
External  Remedies, — The  surface  is 
carefully  cleansed  with  antiseptic  soap 
and  sprayed  with  a  2  per  cent,  carbolic 
acid  solution,  or  with  hydrogen  per- 
oxide,  every  two  hours,  the  atomizer 
being  used  for  ten  minutes  at  each  sit- 
ting.    (Verneuil.) 

Compresses  dipped  in  hot  1 :  4000 
corrosive  sublimate  solution  are  very 
effective.  If  abscess  is  upon  an  ex- 
tremity, a  1 :  4000  corrosive  sublimate 
solution  may  be  employed  as  a  bath 
for  the  limb,  the  latter  being  left  in 
the  solution  several  hours  at  a  time. 

A  solution  of  nitrate  of  silver  (30 
grains  to  the  ounce)  may  be  applied 
frequently  with  a  camel's  hair  pencil. 

Tincture  of  iodine  may  be  applied  in 
the  same  manner  every  three  hours. 

When  the  surface  becomes  very 
tender,  belladonna  ointment  may  be 
rubbed  in  every  two  hours. 

In  abscesses  characterized  by  very 
severe  pain  a  10  per  cent,  solution  of 
cocaine  may  be  introduced  by  cata- 
phoresis,  the  anode  sponge  of  a  gal- 
vanic battery  being  applied  to  the  part. 
The  sittings  should  last  five  minutes, 
and  be  repeated  every  three  hours,  the 
current  not   exceeding  5   milliamperes. 


During  the  intervals  warm  fomenta- 
tions— with  borated,  camphorated,  or 
pure  water — are  of  great  value. 

Encouraging  results  obtained  in  the 
treatment  of  tendon-sheath  phlegmons 
and  suppurating  inflammation  in  gen- 
eral with  superheated  air,  applied  with 
an  ordinary  apparatus.  It  is  used  twice 
a  day  for  two  or  three  hours  each  time, 
maintaining  a  temperature  of  from  90° 
to  110°  C.  (194°  to  230°  F.)  within 
the  frame  at  half  its  height.  Thus  ar- 
ranged, the  temperature  on  the  skin 
averaged  44°  or  47°  C.  (111°  or  116° 
F.),  and  the  acceleration  and  sweating 
induced  seemed  to  keep  the  temperature 
of  the  skin  within  due  bounds.  The  ap- 
plications of  the  hot  air  are  made  the 
da}'-  after  the  abscess  has  been  incised 
and  evacuated,  and  the  cavity  packed 
with  iodoform  gauze.  He  also  states 
that  neglected  injuries  of  the  fingers 
which  v/ould  otherwise  have  necessi- 
tated amputation  healed  under  this 
hot-air  treatment  without  requiring 
operative  measures,  and  recovery  was 
hastened.  This  treatment  also  caused 
an  abolition  of  pain.  (Zentralblatt  fiir 
Chir.,  Oct.  24,   1908.) 

Pads  of  gauze  wrung  out  of  hot  boric 
acid  solution  (an  ounce  to  a  quart  of 
water),  applied  as  hot  as  the  patient 
can  bear  them,  and  well  covered  with 
oiled  silk  to  keep  in  the  heat  and  mois- 
ture, are  the  best;  wherever  applicable, 
as  with  the  hands  or  feet,  the  inflamed 
part  should  preferably  be  submerged 
every  hour  for  a  period  of  five  to  ten 
minutes  in  the  hot  boric  solution  itself. 

Wright's  Bacterial  Vaccines. — 
Treatment  of  staphylococcus  and  strep- 
tococcus infections  (abscess,  suppura- 
tion, etc.)  by  the  therapeutic  inoculation 
of  staphylococcus  and  streptococcus 
vaccines,  as  suggested  and  developed  by 
Sir  A.  E.  Wright,  of  London,  has 
found  many  endorsers.  A  bacterial 
vaccine  is  a  sterilized,  standardized 
emulsion  of  the  infecting  micro-organ- 
ism.   It  is  made  by  scraping  the  film  of 


ABSCESS    (WITHERSTINE). 


203 


a  recent  agar  culture  into  a  1  per  cent, 
salt  solution,  sterilizing  at  60°  C.  (140° 
P\),  and  subsequently  standardizing  to 
a  given  number  of  micro-organisms  per 
cubic  centimeter.  The  method  is,  how- 
ever, a  new  and  complex  one,  and,  until 
its  use  has  been  more  thoroughly  ex- 
plored, it  should  only  be  employed 
under  the  guidance  of  an  expert. 
Whether  an  opsonic  control  of  the  in- 
jections will  always  be  necessary  still 
remains  to  be  shown,  but  in  all  cases 
the  use  of  the  vaccines  should  be  pre- 
ceded by  a  most  careful  bacteriological 
examination,  and  the  particular  vaccine 
should  be  prepared  for  each  individual 
patient.  The  dose  of  staphylococcus 
vaccine  is  100  to  1000  millions;  an 
inoculation  being  made  every  ten  days. 
The  dose  of  streptococcus  vaccine 
which  is  more  toxic  than  staphylococ- 
cus is  20  to  60  millions ;  the  inoculations 
being  repeated  weekly  or  every  two  or 
three  Aveeks. 

The  writer  has  tried  the  vaccine 
treatment  of  staphylococcus  affec- 
tions in  20  cases  and  obtained  en- 
couraging results,  especially  for  re- 
curring furuncles.  Jensen  (Hospital- 
stidende,  Mar.  3,  1909). 

Wright's  comparatively  simple  the- 
ory of  opsonins  and  its  practical 
application  have  been  rendered  need- 
lessly confusing  to  the  average  prac- 
titioner. As  Wright  points  out,  the 
great  causes  of  failure  in  previous 
tuberculin  treatment  was  the  giving 
of  too  large  injections  and  too  fre- 
quent repetition  of  the  dose,  causing 
a  marked  negative  phase  and  keeping 
it  up.  The  writer  has  had  remark- 
able success  in  various  tj^pes  of  sta- 
phylococcus infections;  obstinate 
cases  of  acne  and  furunculosis,  im- 
petigo, palmar  abscess,  and  in  a  very 
distressing  case  of  what  had  been 
called  psoriasis,  but  which  he  thinks 
was  an  extraordinary  case  of  staphy- 
lococcic dermatitis,  and  which  jaelded 
rapidly  to  opsonic  treatment  with  an 


autogenic  culture  of  Staphylococcus 
aureus.  A.  P.  Ohlmacher  (Jour.  Amer. 
Med.  Assoc,  P>b.,   1907;. 

Case  of  furunculosis,  subperiosteal 
abscess  of  the  head,  and  necrosis  of 
the  bones  of  the  skull  treated  by  oper- 
ation and  autogenous  vaccine.  Staphy- 
lococcus aureus  was  ""ecovered  from  the 
parietal  abscess  and  from  the  blood. 
An  autogenous  vaccine  was  made,  and 
4  doses  were  given  at  intervals  of  four 
days.  The  first  dose  was  50,000  000, 
the  second  100,000,000,  and  the  last  2 
150,000,000.  With  no  constitutional  re- 
action, the  local  condition  rapidly  im- 
proved. The  general  condition  of  the 
patient  improved,  but  a  portion  of  the 
bone  at  the  base  of  the  abscess  was 
denuded  and  necrosed.  At  a  later  date 
this  sequestrum  was  removed  and  the 
patient  was  given  3  more  injections  of 
the  autogenous  vaccine  at  four  days' 
interval,  each  dose  being  150,000.000. 
Within  three  weeks  the  patient  was  in 
normal  condition.  The  author  urges 
preference  for  the  autogenous  vaccine. 
G.  G.  Ro'ss  (Monthly  Cyclo.  and  Med. 
Bull.,    Sept.,    1910). 

Bier's  hyperemia  treatment  (passive 
congestion  or  artificial  hyperemia)  of 
acute  abscesses  has  given  excellent 
results  as  to  immediate  relief  of  pain 
and  reduction  of  inflammation. 

Inflammation,  according  to  Bier,  does 
not  in  itself  represent  a  diseased  condi- 
tion, but  is  a  phenomenon  indicating 
the  body's  attempt  to  resist  a  deleterious 
invasion.  To  increase  this  beneficent 
inflammatory  hyperemia  resulting  from 
the  fight  of  the  living  body  against  in- 
vasion, is  the  aim  of  Bier's  hyperemic 
treatment.  The  blood  must,  however, 
continue  to  circulate ;  there  must  never 
be  a  stasis  of  the  blood.  Bier's  method 
artificially  increases  the  redness,  heat, 
and  swelling,  three  of  the  four  symp- 
toms of  acute  inflammation.  He  dis- 
cards all  means  that  tend  to  subdue 
inflammation. 

Bier  produces  this  hyperemia  by  any 


204 


ABSCESS    (WITHERSTINE). 


or  all  of  three  methods :  Elastic  band- 
age or  band,  cupping  glasses,  and  hot 
air.  In  the  use  of  the  elastic  bandage, 
it  should  cause  slight  obstruction  to  the 
return  of  the  blood,  but  not  sufficiently 
firm  as  to  obliterate  the  pulse  beat 
below  or  be  in  the  least  way  annoyable 
to  the  jDatient. 

The  technique  is  correct  if  there  is 
absolutely  no  increase  of  pain,  and  if 
there  is  visible  hyperemia  of  the  parts 
subjected  to  treatment;  the  portion 
distal  to  the  bandage  must  appear  bluish 
or  bluish  red — never  white.  All  dress- 
ings should  be  removed  while  the  com- 
pressing elastic  bandage  is  in  place,  the 
wounds  or  bruises  being  covered  with 
sterile  gauze  kept  in  place  by  a  loosely 
applied  towel.  Under  hyperemic  treat- 
ment any  abscess  must  be  opened  and 
pus  evacuated. 

Acute  inflammatory  processes  require 
application  of  the  hyperemic  treatment 
for  twenty  to  twenty-four  hours  per 
day.  In  chronic  cases,  especially  if 
tuberculous,  shorter  sittings,  from  two 
to  four  hours  per  day. 

In  the  use  of  suction  apparatus  or 
cupping  glasses  to  produce  obstructive 
hyperemia,  the  skin  should  turn  red  or 
bluish  red,  but  never  white ;  circulation 
must  not  be  interrupted.  The  vacuum 
apparatus  of  large  size  is  supplied 
with  a  suction  pump.  These  suction 
glasses  are  applied  for  five  minutes,  six 
times  daily,  with  intervals  of  three 
minutes  between  applications,  in  order 
to  give  the  edema  and  hyperemic  swell- 
ing an  opportunity  to  disappear.  Thus 
the  entire  time  of  treatment  is  three- 
quarters  of  an  hour  each  day. 

Treatment  of  acute  abscess  by  passive 
congestion  has  given  excellent  results. 
Cases  of  purulent  arthritis,  suppuration 
of  tendon  sheaths,  and  acute  abscesses 
and  carbuncles  have  shown  without  ex- 
ception almost  immediate  relief  of  pain 


and  reduction  of  inflammation.  The  ab- 
scess either  became  "cold"  or  its  con- 
tents changed  to  serum  or  were  re- 
sorbed.  Purulent  arthritis  was  treated 
with  passive  motion  after  all  pain  had 
been  relieved.  The  writer  selected  15 
of  the  110  cases  cited  for  brief  descrip- 
tion in  the  article.  All  cases  were 
quickly  cured,  and  it  was  only  rarely 
necessary  to  open  the  abscess.  Of  the 
15  cases  reported,  8  were  resolved,  3 
were  opened,  and  4  were  discharging 
when  admitted.  Bier  (Miinch.  med. 
Woch.,  Jan.  31,  1905). 

By  means  of  artificial  hyperemia,  we 
can  often  abort  an  infective  process  and 
save  the  breaking  down  of  tissue,  or,  if 
at  the  beginning  of  treatment  the  proc- 
ess has  gone  on  to  the  breaking  down 
of  tissues,  the  hyperemic  method  assists 
in  quickening  the  process  of  expulsion 
of  the  products  of  infection  and  also 
the  process  of  repair.  J.  H.  Beaty 
(Jour.  Minn.  State  Med.  Assoc,  Jan. 
15,  1908). 

In  the  use  of  hot  air  to  produce 
hyperemia  we  produce  an  arterial 
hyperemia  which  differs  from  the  ob- 
struction or  venous  hyperemia.  The 
effect  of  hot-air  hyperemia  is  also  dif- 
ferent upon  the  body  and  also  upon  the 
pathologic  process.  This  last  method  is 
apparently  not  used  in  the  treatment  of 
abscess. 

The  author  comments  on  the  value 
of  Wright's  solution  of  sodium  chlo- 
ride, 4  per  cent.,  and  sodium  citrate, 
1  per  cent.,  as  an  agent  for  promot- 
ing drainage  of  abscesses.  The  hy- 
pertonic solution  of  sodium  chloride 
by  osmosis  brings  about  a  flow  of 
lymph  through  the  abscess  walls, 
while  the  sodium  citrate,  by  precipi- 
tating the  calcium  salts  in  the  lymph, 
prevents  the  latter  from  clotting,  and 
thus  perpetuates  the  discharge.  The 
lymph  and  4  per  cent,  salt  solution 
both  antagonize  the  bacteria. 

The  technique  of  treating  an  abscess 
by  this  plan  is  described  as  follows: 
The  abscess  is  opened  by  a  wound  as 
small  as  will  allow  the  cavity  to  be 
wiped  out,  or  thoroughly  emptied  by 


ABSCESS    (WITHERSTINE). 


205 


expression.  The  surrounding  skin  is 
well  cleaned  with  70  per  cent,  alcohol 
and  smeared  up  to  the  very  mouth 
of  the  wound  with  boric  acid  or  euca- 
lyptus vaselin,  in  order  to  avoid  skin 
irritation  from  the  salt  solution.  If 
the  skin  tension  closes  the  opening  a 
bit  of  rubber  dam  may  be  put  in. 
The  wound  is  covered  with  a  volumi- 
nous pad  of  gauze  or  of  absorbent 
cotton  covered  with  gauze,  dripping 
wet  with  hot  salt  and  citrate  solu- 
tion. A  many-tailed  bandage  or  some 
other  application  holds  the  poultice 
in  position,  and  the  part  is  put  at 
rest.  Outside  the  dressing  may  be 
applied  a  hot  flaxseed  poultice  or  a 
hot-water  bottle.  In  any  case,  as 
often  as  the  dressing  gets  cold,  more 
of  the  hot  solution  is  poured  over  the 
whole  dressing  to  wet  and  warm  it 
again,  or  the  dressing  is  removed  and 
the  whole  part  soaked,  if  possible,  or 
bathed  with  the  same  solution. 

The  solution  is  contraindicated  if 
there  is  a  tendency  to  persistent  ooz- 
ing of  blood  from  the  wound,  and 
where  the  formation  of  protective 
adhesions  is  desirable. 

Inguinal  and  axillary  bubo,  abscess 
of  neck,  septic  fingers,  mastoid 
wounds,  otitis  media  after  paracen- 
tesis, all  drain  well  under  this  method. 
The  solution  should  be  used  only  for 
the  first  thirty-six  to  seventy-two  hours 
after  operation,  during  the  acute  stage 
of  inflammation.  The  wound  is  then 
filled  with  glycerin  or  balsam  of  Peru. 
L.  R.  G.  Crandon  (Annals  of  Surg., 
Oct.,  1910). 

The  iodoform  bone-wax  recom- 
mended by  von  Mosetig-Moorhof 
tried  in  5  cases,  in  which  the  wax 
failed  and  was  discharged.  It  is  of 
value  as  a  filling  in  selected  cases 
of  circumscribed  abscess  cavities  in 
Lone.  Its  use  shortens  the  convales- 
cence and  makes  the  dressings  easy 
and  painless.  Simmons  (Annals  of 
Surg.,  Jan.,  1911). 

Bismuth  paste  injection  is  an  agree- 
able procedure  for  the  physician  and 
patient,  practically  painless  and  free 
from  risk,  and  of  value  in  the  treat- 
ment   of    chronic    fistulse    and    abscess 


cavities.     It   is   an   excellent   diagno.stic 
auxiliary    for    determining    the    course 
and  point  of  origin  of  fistulse  and  ab- 
scesses, and,  therefore,  of  great  value  in 
preventing  incomplete  and  useless  oper- 
ations.    The  bismuth  injections  exert  a 
pronounced    efifect    in    relief    of    symp- 
toms by  diminishing  pain  and  secretion 
and  curing  eczema,  and  in  some  cases 
suffice  to  efifect  a  complete  cure.    H.  H. 
Schmid    (Wiener   klin.    Woch.,    Nu.    7, 
1911). 
Antiferment    Treatment. — This    so- 
called     "physiologic     treatment"     was 
recently     introduced     by     Miiller     and 
Peiser.     It  is  based  on  the  antagonistic 
action  the  proteolytic  ferment  derived 
from   leucocytes   is   supposed   to   meet 
from    an    antiferment    in    the    blood- 
serum,   especially  in  morbid   effusions. 
This  antiferment  can  be  obtained  from 
the    patient's    own    blood-serum,    after 
venesection    or    from    puncture    fluids. 
The    contents    of    the    abscess    being 
aspirated,   the   antiferment   is   then  in- 
jected  into   the   cavity   with   the   same 
needle,  enough  being  introduced  to  fill 
it  without  distending  it.     The  contents 
of  the  abscess  are  then  again  removed 
and  the  cavity  is  once  more  filled  with 
fresh  antiferment.    This  is  repeated  the 
next  day  if  the  area  is  still  sensitive,  the 
antiferment  being  left  in.    This  method 
has  not  as  yet  been  tried  sufificiently  to 
warrant  an  expression  as  to  its  merits. 
No  incision  is  required  with  this  tech- 
nique ;     it    is    applicable    only    when    a 
mastitis    or    other    process    is    tending 
to  abscess  formation.     Thirteen  typical 
cases  of  abscesses,  felons,  etc.,  are  de- 
scribed   out    of    an    experience    of    100 
cases,  to  show  the  advantages   of  this 
treatment.     The    antiferment    attracted 
to  the  spot  is  probably  the  main  factor 
in    the    benefit    from    hyperemic    treat- 
ment.   A  serum  rich  in  antiferment  can 
be    kept    on    ice    for   several    weeks    in 
stoppered  vessels.     It  should  be  tested 
from    time    to    time    to    determine    its 
strength.    The  larger  the  proportion  of 
antiferment,  the  better  and  longer  the 


206 


ABSCESS    (WITHERSTINE). 


serum  keeps.  Miiller  and  Peiser  (Bei- 
trage  z.  klin.  Chir.,  Oct.,  1908). 

The  antiferment  serum  not  only  sup- 
plies the  ferment  which  protects  against 
proteolysis,  but  at  the  same  time  it  sup- 
plies vitally  active  leucocytes,  opsonins, 
complements  and  amboceptors,  either 
supplying  them  from  without  or  attract- 
ing them  to  the  spot,  and  thus  summon- 
ing the  most  powerful  defenses  of  the 
organism.  Kolaczek  (Beitrage  z.  klin. 
Chir.,  Dec,  1908). 

The  writer  does  not  use  the  ready- 
made  ferment,  but  injects  a  solution  of 
sodium  nuclein  to  induce  leucocytosis 
in  the  tuberculous  abscess.  This  is 
supplemented  later  by  Roentgen-ray 
treatment.  His  first  case  was  a  tuber- 
culous abscess  in  the  soft  parts  of  the 
thigh,  which  healed  completely  in  three 
sittings  after  it  had  long  resisted  ordi- 
nary treatment.  Goldenberg  (Miinch. 
med.  Woch.,  Jan.  5,  1909). 

Results  in  Dollinger's  surgical  service 
at  Budapest  with  the  Miiller  antifer- 
ment treatment  in  160  cases.  This 
physiological  treatment  proved  satisfac- 
tory in  nearly  every  instance.  Its  spe- 
cial field  is  for  abscesses  unless  they 
are  unusually  extensive  and  deep,  or  the 
patient  much  debilitated,  in  which  case 
incision  is  necessary;  otherwise  all 
that  is  necessary  is  to  paint  the  outside 
with  iodine,  aspirate  the  contents  of 
the  abscess  with  a  puncture  needle  and 
then  inject  pure  serum,  thus  rinsing 
out  the  cavity,  after  which  serum  to 
an  amount-  representing  one-third  or 
one-half  the  amount  of  abscess  contents 
withdrawn  is  injected,  and  a  scrap  of 
gauze  is  laid  over  the  puncture  hole 
and  held  in  place  with  a  strip  of  plaster. 
An  abscess  containing  from  1  to  5  c.c. 
of  pus  heals  in  three  days ;  larger  ones, 
containing  from  20  to  50  c.c.  of  pus, 
heal  in  about  eleven  days.  The  absence 
of  a  scar  is  one  of  the  great  advantages 
of  the  method,  and  the  functional  re- 
sult is  always  better,  as  conditions  are 
more  physiological.  The  writer  has 
never  encountered  any  signs  of  anaph- 
ylaxis, and  the  abscess  never  pro- 
gressed except  in  a  single  instance,  in 
a  very  debilitated  patient.  Gergo 
(Deut.  Zeit.  f.  Chir.,  Jan.,  1910). 


The  writer  has  tried  the  injection  of 
leucofermantin  into  abscesses — a  treat- 
ment based  upon  the  fact  that  a  proteo- 
lytic ferment  is  found  in  the  polymor- 
phonuclear leucocytes.  A  fairly  large 
needle  was  used  for  aspiration  and  in- 
jection, and,  after  evacuating  the  ab- 
scess, he  injected  and  withdrew  a  small 
quantity  of  serum,  so  as  to  clean  out 
the  cavity  as  thoroughly  as  possible 
before  making  the  final  injection,  which 
was  allowed  to  remain ;  a  moist  aseptic 
dressing  was  then  applied.  If  the  aspi- 
ration had  to  be  repeated,  the  needle 
was  inserted  through  the  old  puncture, 
so  as  to  save  pain.  The  quantity  of 
serum  left  in  varied,  according  to  the 
size  of  the  abscess,  from  2  to  IS  c.c. 
The  author  feels  convinced  that  the 
principle  on  which  the  method  is  based 
is  sound,  and  that  it  opens  up  a  new 
pathway  in  the  physiological  treatment 
of  suppurative  inflammation.  Mac- 
Ewan  (Brit.  Med.  Jour.,  Jan.  22,  1910). 

Antiferment  serum  exerts  a  slight 
degree  of  curative  action  upon  sup- 
puration, but  must  be  brought  into 
intimate  contact  with  the  whole,  of 
the  suppurating  surface.  It  is  suited 
only  for  superficial,  well-defined  ab- 
scesses. Boit  (Med.  Klinik,  Apr.  16, 
1911). 

Surgical  Measures. — Incision  and 
drainage  tersely  indicate  the  surgical 
treatment  of  acute  abscess.  If  sup- 
puration cannot  be  avoided,  the  ab- 
scess should  be  opened  under  rigid 
asepsis,  as  soon  as  an  adequate  quan- 
tity of  pus  has  formed  to  constitute 
an  abscess  sufficient  in  size  to  be 
recognized  b}^  the  surgeon  as  such 
(Senn),  or  as  soon  as  the  presence  of 
pus  has  been  determined  by  the  ex- 
ploring needle  or  syringe.  An  early 
incision  prevents  excessive  loss  of  tis- 
sue, less  deformity  and  leaves  smaller 
scar. 

If  a  local  anesthetic  is  necessary, 
one  of  the  following  may  be  used : 
Twenty  drops  of  a  1  to  5  per  cent, 
solution    of    cocaine    introduced    sub- 


ABSCESS    (WITHERSTINE). 


207 


cutaneously  near  the  abscess-  ether 
sprayed  over  the  seat  of  the  abscess 
until  local  numbness  is  experienced ; 
chloride  of  methyl  or  chloride  of  ethyl 
vapor.  The  latter  is  especially  effica- 
cious ;  the  parts  turn  white  when 
ready, — generalh'  in  about  two  min- 
utes. Seltzer  water  spurted  over  the 
surface  may  be  used  to  advantage 
when  none  of  the  other  agents  can  be 
obtained. 

To  open  an  ordinary  abscess  a 
single  small  incision  suffices;  but,  if 
it  is  large,  several  small  incisions 
should  be  made  to  render  perfect 
evacuation  of  its  contents  possible  by 
drainage.  If  the  abscess  is  super- 
ficial, the  skin  alone  should  be  cut, 
but  if  it  is  deep  seated  the  skin 
and  fascia  should  be  incised  and  the 
grooved  director,  or  the  points  of  a 
pair  of  forceps,  used  to  reach  the  pus, 
the  opening  being  kept  patent  with 
forceps.  The  cavity  is  then  thor- 
oughl}^  emptied  and  syringed  out  with 
1 :  10,000  corrosive  sublimate  solu- 
tion, or,  better,  with  normal  salt  solu- 
tion or  boric  acid  solution,  until  the 
fluid  comes  out  perfectly  clear.  Pres- 
sure with  the  fingers  is  to  be  avoided, 
but  loose  necrotic  tissue  should  be  re- 
moved if  it  can  be  done  without 
injury  to  surrounding  structures.  The 
incision  and  its  surroundings  are  then 
carefully  washed  with  one  of  the 
solutions  mentioned,  and  an  aseptic 
drainage-tube  inserted.  The  wound 
is  dusted  with  iodoform  or  dermatol, 
and  an  antiseptic  dressing  is  applied, 
exerting  slight  pressure  with  bandage. 
If  the  abscess  is  deep,  the  drainage- 
tube  should  be  shortened  dail}^;  if  it  is 
superficial,  the  drainage-tube  can  be 
withdrawn  the  second  or  third  day. 

Drainage  b}^  means  of  rubber  drain- 
age-tubes of  sufficient  size  is  preferred 


to  tlie  use  of  gauze.  Two  tubes 
placed  side  by  side  facilitate  irrigation 
when  necessary. 

A  good  plan  is  to  incise  the  abscess 
freely,  evacuate  its  contents,  wipe  off 
the  wall  with  10  per  cent,  iodoform 
gauze,  aided  by  the  curette,  clean  the 
cavity  as  perfectly  as  possible,  usin.c^' 
gauze  freely  to  wipe  out  all  debris. 
The  wound  is  closed  with  sutures 
placed  as  deeply  as  possible  to  ap- 
proximate wide  areas  of  tissue.  Pres- 
sure is  kept  up  over  the  abscess  to 
prevent  its  filling  with  serum,  and  a 
firm  antiseptic  dressing  is  applied. 
The  result  in  the  majority  of  cases 
has  been  excellent.  In  only  7  cases 
was  there  any  breaking  down  of  the 
wound  and  a  resulting  sinus.  Iodo- 
form emulsion  was  abandoned  on  ac- 
count of  the  dehydrating  action  of 
the  glycerin.  In  48  of  his  cases  the 
cavity  has  remained  perfectly  closed 
and  aseptic  for  periods  varying  from 
four  months  to  six  years.  Starr 
(Brit..  Med.  Jour.,  Oct.  13,  1906). 

When  it  is  necessary  to  traverse  the 
peritoneal  or  pleural  cavity  in  order 
to  reach  a  collection  of  pus,  infection 
may  be  avoided  by  carefully  packing 
off  the  cavity  with  gauze,  so  as  to 
form  a  sort  of  well  with  the  abscess 
at  the  bottom. 

The  kind  of  dressing  used  after  the 
abscess  has  been  opened  will  depend 
upon  the  condition  of  the  parts.  If 
there  be  much  infiltration  of  the  tis- 
sues, swelling,  and  pain,  a  hot,  moist 
antiseptic  dressing  is  to  be  applied,  as 
it  favors  absorption  and  is  at  the  same 
time  soothing  to  the  patient.  Any 
weak  antiseptic  solution  (barring  car- 
bolic acid  for  fear  of  gangrene)  may 
he  used,  as  boric  acid,  bichloride  of 
mercury  (not  stronger  than  1  to  20,- 
000),  or  normal  salt  solution.  The 
dressings  (wet  or  dry)  while  suffi- 
ciently firm  to  favor  collapse  and 
adhesion  of  abscess  walls  should  yet 


208 


ABSCESS    (WITHERSTINE). 


be  loose  enough  to  permit  of  easy 
absorption  and  evaporation  of  dis- 
charges. A  generous  dressing  of 
gauze  covered  with  absorbent  cotton 
is  advised. 

Thirty-two  cases  of  abscess  treated 
by  the  Otis  method :  The  skin  about 
the  affected  area  is  scrubbed  with  green 
soap  and  washed  with  sulphuric  ether 
and  then  with  bichloride  (1  to  1000). 
A  narrow  bistoury  is  then  inserted  into 
the  abscess  cavity,  and  the  contents 
gently,  but  thoroughly,  squeezed  out ; 
the  cavity  is  irrigated  with  bichloride 
(1  to  1000)  and  immediately  filled  to 
moderate  distention  with  warm  iodo- 
form ointment  (10  per  cent,  iodo- 
form and  vaselin),  care  being  taken  not 
to  use  a  sufficient  degree  of  heat  to 
liberate  free  iodine.  An  ordinary  glass 
gonorrheal  syringe  is  used,  the  plunger 
being  removed,  -and  the  barrel  warmed 
in  the  flame  of  an  alcohol  lamp  and 
filled  with  ointment  by  means  of  a  spat- 
ula. On  finishing  the  injection,  at  the 
instant  of  withdrawing  the  syringe  from 
the  wound,  a  compress  wet  with  cold 
bichloride  solution  is  applied,  which  in- 
stantly solidifies  the  ointment  at  the  ori- 
fice, preventing  the  escape  of  that  into 
the  abscess  cavity.  Edwin  M.  Has- 
brouck  (N.  Y.  Med.  Jour.,  June  13, 
1896) . 

Puncture  and  disinfection  recom- 
mended for  abscess  instead  of  incision 
and  drainage,  in  order  to  avoid  muti- 
lating scars  and  slow  convalescence. 
The  writer's  method  is  as  follows :  1. 
After  careful  disinfection,  and  under 
infiltration  anesthesia,  he  punctures  the 
most  dependent  portion  with  a  large 
trocar  or  pointed  scalpel,  and  gently 
expresses  the  pus.  This  is  better  than 
aspiration.  2.  The  cavity  is  then  thor- 
oughly irrigated  through  the  trocar 
with  a  1 :  1000  solution  of  corrosive  sub- 
limate. This  can  be  used  in  large  quan- 
tities, as  the  abscess  wall  does  not  ab- 
sorb. He  has  found  this  strength  most 
satisfactory.  3.  The  remnants  of  the 
corrosive  sublimate  solution  are  care- 
fully squeezed  out  and  the  abscess  is 
partly  distended  with  a  solution  of  from 
5  to  10  per  cent,  iodoform  glycerin.    A 


moist  dressing  with  a  firm  pressure 
bandage  is  then  applied.  This  method 
is  useful  in  every  form  of  acute  exter- 
nal abscess,  following  the  principle 
originally  laid  down  by  Henle  for  cold 
abscess.  To  date  the  writer  has  treated 
2)1  cases  with  good  results  in  all  ex- 
cept abscesses  of  caseous  tuberculous 
glands,  which  generally  required  a  sec- 
ondary curetting,  though  they  were 
none  the  worse  for  the  preliminary  con- 
servative treatment.  DeWitt  Stetten 
(Jour.  Amer.  Med.  Assoc,  May  11, 
1907). 

Peroxide  of  hydrogen  is  prophylactic 
and  curative  medicament  in  the  treat- 
ment of  suppurative  skin  lesions  so 
common  in  infants.  A  twelve-volume 
solution  is  ample  as  a  skin-wash  twice 
daily.  This  rapidly  cures  superficial 
lesions.  Abscesses  must  obviously  be 
evacuated  before  the  peroxide  solution 
is  used.  Cochart  (Jour,  de  Med.  de 
Paris,  April  21,  1901). 

Personal  method.  1.  Cleanse  the 
skin  as  in  operating  on  sterile  tissues. 
2.  Make  an  incision  long  enough  to  per- 
mit of  the  pus  being  freely  evacuated 
and  the  pyogenic  membrane  rubbed 
clean  and  smooth  with  gauze  wrapped 
around  the  finger.  3.  Having  emptied 
the  abscess  cavity  as  completely  as  pos- 
sible, pack  it  tightly  with  gauze  (1  to 
1000  mercury  bichloride  gauze,  dry) 
and  apply  a  wool  dressing  and  bandage 
as  firmly  as  possible.  4.  At  the  end  of 
forty-eight  hours  remove  the  packing 
and  dress  the  wound  as  if  it  were  a 
simple  incision,  that  is,  do  not  pack 
or  drain  at  all,  but  simply  fix  a  gauze 
and  wool  dressing  firmly  in  place  with 
a  bandage.  This  dressing  will  require 
changing  only  once  in  three  or  four 
days  until  the  incision  is  soundly  healed, 
the  sides  of  the  abscess  cavity  will  unite 
promptly,  and  there  is  no  outpouring  of 
pus  from  it.  From  the  time  when  the 
packing  is  removed  it  is  practically  a 
simple  incised  wound  that  is  being 
treated. 

There  results  rapid  healing;  the 
constitutional  symptoms  are  gotten  rid 
of  almost  at  once ;  as  the  dressing  re- 
quires renewal  very  seldom  the  doctor 
can  do  it  himself  and  so  avoid  the  risk 


ABSCESS    (WITHERSTINE). 


209 


of  a  secondary  mixed  infection.  J. 
Phillips  (Brit.  Med.  Jonr.,  M-iy  16, 
1908). 

COLD,      OR      TUBERCULOUS, 

ABSCESS.— Symptoms.— These  ab- 
scesses frequently  attain  a  large  size, 
and  last  for  months  without  their  pres- 
ence being  detected.  Besides  failing 
general  health,  the  symptoms  of  the 
causative  trouble  are  the  only  prom- 
in-ent  ones.  The  spine,  the  hips,  the 
genitourinary  tract,  and  the  lymphatic 
glands  are  the  organs  most  prone  to 
tuberculous  disorders  giving  rise  to 
cold  abscesses.  They  sometimes  ap- 
pear several  months  and  even  years 
after  the  beginning  of  the  primary 
disease. 

The  general  symptoms  of  tuberculous 
abscesses  do  not  closely  resemble 
those  of  ordinary  suppuration,  but 
vary  with  the  resisting  powers  of  the 
individual.  There  is  nearly  always  a 
slight  evening  rise  in  temperature 
(hectic)  followed  by  a  subnormal 
temperature  in  the  morning.  Loss  of 
flesh  and  strength  and  the  presence 
of  anemia,  more  or  less  marked,  are 
usual,  although  they  may  not  occur 
unless  mixed  infection  (tubercular 
and  purulent)  takes  place.  There  is 
no  leucocytosis.  Amyloid  (albumi- 
noid) degeneration  may  appear  as  a 
later  phenomenon. 

The  local  symptoms  are  as  a  rule  very 
slight,  and  are  indicative  of  the  effects 
of  pressure  upon  organs  or  nerves 
rather  than  activity  in  the  abscess 
itself.  Large  fluctuating  abscesses 
may  exist  in  various  parts  of  the  body, 
even  about  joints,  without  serious  dis- 
comfort to  the  patient.  No  pain  is 
experienced  as  a  rule;  cold  abscesses 
are  not  even  tender  to  the  touch. 
There  is  no  redness  until  the  abscess 
is  about  to  break,  the   focus   of  the 


liquid  mass  being  otherwise  too 
deeply  seated,  the  skin  covering  the 
abscess  remaining  white  or  normal  in 
color  unless  the  abscess  be  just  be- 
neath the  surface,  which  phenomenon 
has  caused  the  name  "white  swelling" 
to  be  applied  in  tuberculosis  of  the 
knee. 

The  above  symptoms  usually  follow 
or  are  coincident  with  the  sudden 
appearance  of  a  swelling.  Though 
generally  soft,  it  may  be  hard,  and 
sug-gest  a  tumor  in  the  vicinity  of  the 
spinal  column  (Pott's  disease),  above 
or  below  Poupart's  ligament,  after 
burrowing  along  the  psoas  muscle 
(psoas  abscess),  on  the  inner  aspect 
of  the  thigh,  or  in  the  lumbar  region 
(lumbar  abscess),  etc.  In  the  neck 
cold  abscesses  are  usually  due  to  dis- 
ease of  the  neighboring  cervical 
lymphatic  glands.  The  skin  either 
remains  normal  or  gradually  becomes 
thinned  and  softened  until  an  external 
opening  is  formed. 

Fluctuation,  usually  detected  with 
ease,  is  sometimes  hidden  by  a  thick 
investing  layer  of  lymph,  which  gives 
the  mass  a  peculiar  tension,  suggest- 
ing a  lipoma  or  some  other  hard 
growth.  Aneurisms  sometimes  con- 
vey the  sensation  produced  by  a  cold 
abscess :  a  fact  to  be  borne  in  mind 
when  operative  procedures  are  under 
consideration. 

Pathology. — A  cold  abscess  can  al- 
ways be  traced  to  a  specific  inflam- 
matory process,  and  almost  invariably 
to  one  of  a  tubercular  nature.  Where 
the  confluent  masses  in  the  center  of 
a  nodule  begin  to  break  down,  there 
is  formed  a  collection  of  material  sur- 
rounded by  tuberculous  tissue.  This 
material  becomes  infiltrated  with  leu- 
cocytes, and  thus  is  produced  a  cavity 
containing  fluid  fatty  material,  frag- 


t-w 


210 


ABSCESS    (WITHERSTINE). 


ments  of  cells^  and  leucocytes,  around 
which  there  is  granulation  tissue  filled 
with  tubercles.  In  this  way  a  tuber- 
culous abscess  is  formed.  It  seems  at 
times  to  be  quite  a  matter  of  accident 
whether  the  abscess  breaks  into  the 
joint  or  finds  its  way  by  a  more  cir- 
cuitous route  into  the  surrounding 
connective  tissue.  As  the  tubercu- 
lous masses  spread,  caseation  takes 
place  at  dififerent  points  in  the  wall, 
and  the  masses  are  discharged  into 
the  cavity  of  the  abscess ;  but  the 
spread  of  the  abscess  is  effected  gen- 
erally by  what  is  termed  ''burrowing 
of  pus."  This  burrowing  occurs  in 
various  directions,  and  large  collec- 
tions of  pus  altogether  out  of  propor- 
tion to  the  original  lesion  are  formed, 
and  are  known  as  cold  abscesses. 

AMiat  has  been  called  a  chronic  ab- 
scess is  A'ery  often  no  abscess  at  all. 
In  tubercular  processes  the  product 
of  tissue  proliferation  undergoes  co- 
agulation necrosis,  and  disintegrates 
into  a  granular  mass,  which,  when 
mixed  with  a  sufficient  quantity  of 
serum,  forms  an  emulsion  that  micro- 
scopically resembles  pus,  but  under 
the  microscope  shows  none  of  the 
histological  elements  which  are  found 
in  true  pus.  An  abscess  can  only  be 
called  such  if  it  contains  pus.  A  true 
chronic  abscess  can  originate  in  a 
tubercular,  actinomycotic,  or  syph- 
ilitic lesion,  when  the  granulation 
tissue  is  secondarily  infected  by  the 
localization  of  pus-microbes,  which 
convert  the  embryonal  cells  into  pus- 
corpuscles. 

Differential  Diagnosis. — The  con- 
comitant disorder  usuall}^  makes  a 
diagnosis  easy  in  a  case  of  cold  ab- 
scess ;  but  occasionally  the  swelling  is 
the  only  indication  of  ill  health,  and 
it   is   important   to   determine^   under 


such  circumstances,  the  nature  of  the 
pus.  The  macroscopical  appearances 
of  "laudable"  pus  and  of  "sanious" 
pus  are  frequently  so  similar  that  a 
dc  z'isu  diagnosis  is  not  justified.  Bac- 
teriological examination  of  the  con- 
tents of  such  abscesses  will  show  con- 
clusively whether  they  are  true  pus- 
containing  abscesses  or  whether  or 
not  they  are  pseudo-abscesses.  If 
cultivations  are  made  of  their  con- 
tents, pus-microbes  will  grow  upon 
proper  nutrient  media  if  it  be  a  true 
abscess,  while  from  the  contents  of  a 
pseudo-abscess  only  the  microbes  of 
the  primary  infection  can  be  cul- 
tivated. The  information  obtained 
by  the  discovery  of  the  essential 
cause  can  be  confirmed  by  inoculation 
experiments. 

Prognosis. — The  walls  of  cold  ab- 
scesses are  usually  tense  and  tough, 
and  are  lined  with  cheesy  tuberculous 
material.  They  do  not  tend  to  col- 
lapse, as  is  the  case  with  acute  absces- 
ses, and  for  that  reason  are  healed 
with  difficulty.  AMien,  however,  the 
seat  of  the  original  trouble  can  be 
reached  and  successfully  treated,  the 
fluid  in  the  parts  of  the  abscess  tract 
is  absorbed,  and  the  caseous  matter 
undergoes  calcification.  This  fortu- 
nate issue  of  the  case  is  seldom  met 
with,  however,  and  the  abscess  usu- 
ally continues,  the  primary  etiological 
factor  acting  as  a  drain  for  the  dis- 
eased area.  The  prognosis,  therefore, 
depends  upon  the  result  obtained  in 
the  treatment  of  the  latter. 

Surgical  Treatment.  —  Experience 
has  shown  that  when  such  a  cold,  or 
tuberculous,  abscess  opens  spontane- 
ously, or  is  incised  in  a  careless  wa3^ 
profuse  suppuration  and  hectic  fever 
follow,  with  only  too  often  a  speedy 
fatal     result     from     septic     infection. 


ABSCESS    (WITHERSTINE). 


211 


Unless  the  surroundings  of  the  patient 
admit  of  carrying'  out  the  antiseptic 
treatment  to  its  full  and  perfect  extent, 
a  chronic  abscess  should  not  be  evac- 
uated by  incision.  It  should  be  aspi- 
rated. When  an  incision  can  be  made, 
it  should  be  free,  and  the  cavity  should 
be  thoroughly  curetted,  cleansed,  irri- 
gated with  normal  salt  solution  or  a 
solution  of  boric  acid,  disinfected,  and 
iodoformized,  then  sutured,  drained, 
and  treated  as  a  recent  wound. 

The  early  recognition  of  cold  ab- 
scesses will  enable  one  to  dissipate  or 
to  nip  them  in  the  bud.  When  they  are 
present  at  the  time  the  cases  come  un- 
der observation,  they  should  be  treated 
with  indifference  so  long  as  they  do  not 
interfere  with  the  proper  adjustment 
of  good  protection  apparatus.  If  they 
are  in  the  way,  or  if  they  show  a  dis- 
position to  burrow  and  encroach  on 
parts  that  it  is  desirable  to  keep  free 
from  such  invasion,  aspiration  should 
be  resorted  to  and  cultures  made  in 
order  to  determine  their  virulency.  If 
aspiration  fails,  incisions  under  rigid 
asepsis,  large  enough  only  to  permit 
evacuation  of  the  contents,  should  be 
relied  on,  and  the  introduction  of  chem- 
icals should  be  refrained  from.  The 
wound  should  be  closed  by  suture  under 
the  same  rigid  asepsis.  When  the  ab- 
scess lies  directly  over  a  bone  focus 
that  can  be  easily  reached,  the  incision 
should  be  made  large  enough  to  re- 
move the  focus,  and  at  the  same  time 
permit  removal  by  curette  or  scissors 
of  the  lining  of  the  sac  and  all  necrotic 
tissue  contiguous  thereto.  It  should 
then  be  closed  aseptically,  employing 
drainage  for  not  over  forty-eight  hours. 
If  longer  drainage  is  demanded,  means 
should  be  devised  by  which  asepsis  in 
dressings  may  be  continued  indefinitely, 
and  a  mixed  infection  looked  on  as  a 
calamity.  Sinuses  should  be  well 
drained,  the  foci  on  which  they  depend 
should  be  treated  if  involving  joints  by 
perfect  and  long-continued  immobiliza- 
tion, with  due  regard  to  fresh  air  and 
a  high  state  of  nutrition.    V.  P.  Gibney 


(Jour.  Amer.  Med.  Assoc,  Oct.  29, 
1904) . 

Conclusions  based  on  26  reported 
examinations  of  tuberculous  ab- 
scesses: Tuberculous  abscesses  will 
frequently  disappear  under  thorough 
protective  treatment,  and  will  not  re- 
quire an  incision.  Exploratory  punc- 
ture of  the  joints  shotild  be  made 
early,  and  of  the  abscess  preceding 
any  operation,  for  diagnostic  pur- 
poses. The  method  of  operation 
should  be  decided  on  from  the  results 
of  the  laboratory  examinations.  When 
the  abscess  is  reported  sterile  it 
should  be  thoroughly  incised,  curetted, 
and  closed  without  drainage,  under 
the  most  careful  aseptic  precautions. 
When  the  abscess  report  shows  large 
numbers  of  tubercle  bacilli,  the  in- 
cision should  be  cauterized  before 
the  sac  is  incised,  with  thorough  cu- 
rettage, partial  closure,  and  drainage 
for  not  over  forty-eight  hours,  the 
strictest  asepsis   being  maintained. 

When  the  cultures  show  mixed  in- 
fection the  abscess  should  be  incised, 
thoroughly  curetted,  washed  with  a 
formalin  solution,  partially  closed 
aseptically,  and  drained  for  not  over 
forty-eight  hours.  If  the  clinical 
symptoms  and  X-ray  show  an  ac- 
cessible focus  of  disease  this  should 
be  thoroughly  removed  at  the  same 
time  the  abscess  is  incised,  by  curet- 
tage, erasion,  partial  closure,  and 
drainage  for  a  short  period.  Cultures 
should  be  taken  from  sinuses,  and,  if 
sterile,  the  sinus  should  be  treated  by 
absolute,  thorough,  and  complete  im- 
mobilization of  the  tuberculous  area, 
with  partial  closure  and  aseptic 
dressings.  If  the  cuUvres  taken  from 
the  sinuses  show  tubercle  bacilli  the 
part  should  be  thoroughly  curetted, 
immobilized,  and  treated  with  a  sat- 
urated solution  of  methylene  blue.  If 
the  cultures  from  the  sinuses  show 
mixed  infection  they  should  be  thor- 
oughly curetted  under  strict  aseptic 
precautions,  the  diseased  part  should 
be  immobilized,  and  the  general  con- 
dition should  be  treated  by  serum 
therapy.  Young  (Amer.  Jour,  of 
Orthop.    Surg.,  July,    1907). 


212 


ABSCESS    (WITHERSTINE). 


On  general  principles,  necrosed  or 
detached  bone  should  be  looked  for  in 
all  cases.  Strict  antiseptic  precautions 
are  imperative  to  avoid  mixed  infection 
(bacilli  of  tuberculosis  and  pyogenic 
cocci).  Preliminary  precautions  should 
be  taken  to  meet  violent  hemorrhage 
due  to  vascular  erosion. 

When  there  is  local  inflammation  and 
spontaneous  opening  of  the  abscess  is 
probable,  there  should  be  a  free  inci- 
sion, a  thorough  scraping  of  its  walls 
with  Volkmann's  curette  to  transform 
the  suppurating  surfaces  into  bleeding 
ones.  The  cavity  is  then  cleansed  with 
a  5  per  cent,  solution  of  carbolic  acid,  a 
long  drain  is  applied,  and  the  wound  is 
stitched  as  far  as  the  drain.  An  anti- 
septic dressing  is  then  applied.  (Volk- 
mann,  Trelat,  Pozzi.)^ 

After  opening  the  abscess  the  cavity 
may  be  washed  out  with  peroxide  of 
hydrogen  in  10  per  cent,  solution  or 
packed  with  iodoform  gauze.  Removal 
of  the  limiting  sac  is  then  performed 
by  decortication,  the  steps  being:  free 
incision,  the  sac  detached  with  finger 
or  spatula  and  removal,  and  the  cavity 
closed  immediately.     (Lannelongue.) 

The  removal  of  the  limiting  sac  is 
facilitated  by  filling  the  wound  with 
paraffin ;  the  mass  can  then  be  removed 
as  if  it  were  a  lipoma.     (Cazin.) 

A  psoas  abscess  should  be  opened  in 
the  loin  and  groin  when  possible.  In 
the  loin  the  incision  should  be  made 
through  the  external  and  internal  ob- 
lique, transversalis,  and  lumbar  fascia, 
along  the  outer  edge  of  the  erector  spine 
to  the  edge  of  the  quadratus  lumborum. 
The  latter  muscle  and  the  transversalis 
fascia  are  divided  on  a  level  with  the 
tip  of  the  second  or  third  lumbar  trans- 
verse process,  avoiding  the  lumbar  ar- 
teries. The  sheath  and  the  psoas  are 
then   perforated   with   the   finger  or   a 


trocar.  A  counteropening  is  then  made 
below  Poupart's  ligament  to  form  a 
tunnel,  into  which  a  large-size  drainage- 
tube  is  inserted.  This  is  replaced,  later 
on,  by  a  tube  at  each  end  to  obtain  oblit- 
eration, beginning  from  the  center  of 
the  canal.  If  one  incision  is  preferred 
the  loin  should  be  selected. 

Aspiration  and  Injections.  —  When 
no  local  inflammation  indicates  that  the 
abscess  is  soon  to  open,  the  fluid  may 
be  withdrawn  with  a  large  aspirator;  a 
5  per  cent,  solution  of  carbolic  acid  is 
injected  and  then  aspirated.  This  pro- 
cedure is  renewed  until  the  solution 
withdrawn  is  perfectly  clear.  A  Lister 
bandage  is  then  applied,  insuring  slight 
pressure.  Five  days  later  the  treatment 
is  renewed.  About  five  sittings  are  re- 
quired.    (Boeckel.) 

Injection  fluids:  Iodoform,  1  part; 
ether,  5  parts ;  distilled  water,  5  parts. 
Injection  not  to  be  renewed  while  iodo- 
form is  being  excreted  in  the  urine. 
(Mosetig-Moorhof,  Verneuil.) 

Less  painful  is  a  mixture  of  1  part  of 
iodoform  to  10  of  glycerin  (Billroth) 
or  of  olive  oil  (Bruns). 

Intoxication  may  be  prevented  by 
sterilizing  the  iodoform  and  excipient 
(except  ether)  by  heating  at  212°  F. 
separately.     (Tillmann.) 

Mixture  used  for  injections  into  cavi- 
ties of  tuberculous  abscesses  after  as- 
piration: Iodoform,  5  grams;  ether, 
10  grams ;  guaiacol  and  creosote,  2 
grams  of  each,  and  sterilized  olive  oil, 
100  c.c.  Solutions  of  iodoform  com- 
bined with  ether  were  also  commonly- 
used.  Out  of  29  cases  of  spinal  caries 
with  abscesses,  27  were  cured,  2  remain 
with  sinuses  which  are  not  infected  and 
in  which  the  discharge  is  diminishing 
and  the  general  condition  is  good. 
There  were  33  cases  of  hip  disease;  of 
these,  32  patients  were  cured,  1  re- 
mained with  a  sinus.  In  this  case  the 
sinus  was  serious,  due  to  a  secondary 


ACETANILIDE    (SAJOUS). 


213 


infection  caused  by  improper  steriliza- 
tion. The  number  of  aspirations  was 
from  1  to  21  in  each  case.  At  a  crip- 
ples' home  23  closed  tuberculous  ab- 
scesses connected  with  lesions  in  the 
spine,  hip,  and  knee  were  treated  by- 
aspiration  ;  8  spinal  abscesses  were  as- 
pirated. The  greatest  number  of  as- 
pirations required  for  any  one  case  was 
12 ;  the  average  number  required  was  3. 
All  the  patients  are  apparently  cured, 
and  in  no  case  has  a  sinus  formed. 
Thirteen  cases  of  abscess  in  connection 
with  tuberculous  disease  of  the  hip 
were  treated  by  aspiration.  Of  these  12 
patients  had  been  apparently  cured.  In 
1  case  a  small  sinus  persists,  but  is 
not  infected.  The  greatest  number  of 
aspirations  required  for  any  one  case 
was  14.  The  average  number  was  4. 
Two  abscesses  in  connection  with  the 
knee-joint  have  been  similarly  treated, 
and  both  patients  are  apparently  well. 
Calve  and  Gauvain  (Lancet,  Mar.  5, 
1910). 

Boric  acid,  a  4  per  cent,  solution,  may 
be  used  as  above  (Menard),  or  naph- 
thol  and  camphor,  1  part  each.  About 
thirty  sittings  are  usually  required. 

The  lesion  being  a  tuberculous  one, 
the  general  system  should  be  treated  ac- 
cordingly. Nutritious  food,  including 
a  free  supply  of  milk  and  eggs,  pure 
air,  sunlight,  and  sea-air,  if  possible, 
are  indicated,  as  well  as  tonics  and 
alteratives  (codliver  oil  and  hypo- 
phosphites,  iodine,  iodides,  arsenic, 
quinine,  strychnine,  etc.). 

In  the  Middlesex  Hospital,  London, 
Kellock  obtained  good  results  from  the 
use  of  sulphur  in  tuberculous  sinuses 
and  cavities,  and  remarks  the  superior- 
ity of  this  agent  over  iodoform  under 
similar  conditions.  J.  R.  Eastman 
(Jour.  Indiana  State  Med.  Assoc,  Jan. 
15,  1908). 

One  hundred  cases  of  tuberculous 
abscess,  including  tuberculosis  of 
bony  structures,  joints,  lymph-glands, 
tendons,  etc.,  were  treated  with  tryp- 
sin by  the  writer.  The  procedure  is 
described    as    follows:     0.1     Gm.    of 


trypsin  is  introduced  in  sterile  flasks 
of  10  c.c.  size,  and  the  mouths  of  the 
flasks  plugged  with  cotton.  Before 
using,  each  flask  is  filled  with  normal 
saline,  giving  a  1  per  cent,  solution 
of  trypsin.  The  mixture  should  be 
freshly  prepared  each  day,  as  it  is 
unstable.  The  abscesses  are  entered 
with  a  large  trocar  and  emptied  as 
much  as  possible  by  pressure.  One 
to  2  cm.  of  the  trypsin  solution  is 
then  injected  and  the  opening  cov- 
ered with  adhesive  plaster.  Injec- 
tions are  given  every  five  to  seven 
days.  Joint  cases  are  always  immo- 
bilized  in   plaster   dressings. 

After  a  few  injections  the  pus,  orig- 
inally yellowish,  assumes  a  brownish- 
red  color,  owing  to  admixture  of 
blood,  and  resembles  an  emulsion. 
This  method  gives  good  results  in 
"ganglion"  and  cold  abscesses  of 
small  size.  Small,  bony  foci  may  also 
be  cured.  In  burrowing  abscess  for- 
mations trypsin  has  no  particular 
advantage  over  iodoform  and  glyce- 
rin. It  should  not  be  used  at  all  in 
cases  of  joint  tuberculosis  with  ex- 
tensive bony  foci,  or  in  lymphatic 
foci  which  have  not  yet  become  soft- 
ened or  are  in  the  stage  of  caseation. 
No  untoward  results  followed  the  in- 
jections, except  slight  pain,  lasting 
a  half  to  one  hour,  and  in  some  in- 
stances a  painful  edema  surrounding 
the  focus,  generally  only  temporary, 
but  sometimes  persistent.  A.  Briining 
(Deut.  med.  Woch.,  Sept.  1,  1910). 

C.  Sumner  Witherstine, 

Philadelphia. 

A.  C.  E.  MIXTURE.  See  Chloro- 
form. 

ACETANILIDE.  —  Acetanilidum, 
formerl}'  known  under  the  name  of 
antifebrine,  is  obtained  by  boiling 
aniline  with  glacial  acetic  acid.  It  is 
the  monacetyl  derivative  [CgHs.NH.- 
CH3CO]  of  aniline. 

PROPERTIES.  —  Acetanilide  oc- 
curs as  a  white  or  colorless  shining 
powder  or  as  crystalline  laminse.     It 


214 


ACETANILIDE    (SAJOUS). 


is  odorless,  but  has  a  slightly  burning 
and  bitter  taste. 

DOSE. — The  dose  of  acetanilide  is 
3  to  5  grains  (0.2  to  0.325  Gm.)  in 
adults;  the  tendency,  however,  is  to 
employ  smaller  quantities.  In  chil- 
dren, according  to  Griffith,  the  coal- 
tar  products  of  this  class  are  well 
borne;  %  to  ><  grain  (0.016  to 
0.033  Gm.)  may  be  given  at  6  months, 
increasing  the  dose  by  Yi^  grain  with 
each  year,  until  the  adult  dose  is 
reached.  The  action  of  acetanilide 
should  be  closely  watched  in  weak 
subjects  and  in  hysterical  women. 

Out  of  274  observers  who  stated  that 
they  used  acetanilide,  17,  or  6.2  per  cent, 
employed  less  than  2  grains  as  a  mini- 
mum dose  for  adults;  113,  or  41.2  per 
cent.,  employed  2.5  grains  or  less  as  a 
minimum  dose,  and  155,  or  56.5  per 
cent.,  employed  from  3  to  5  grains  as 
a  minimum  dose.  Two  hundred  and 
fort}^  or  a  little  over  87.5  per  cent., 
never  exceeded  a  dose  of  5  grains,  and 
34,  or  not  quite  12.5  per  cent.,  employed 
doses  exceeding  5  grains. 

An  examination  of  a  number  of  pre- 
scriptions for  adults  on  file  in  vari- 
ous pharmacies  in  Washington,  D.  C, 
brought  into  court  as  evidence,  showed 
the  average  dose  of  acetanilide  pre- 
scribed was  2.43  grains.  Kebler,  Mor- 
gan and  Rupp  (U.  S.  Dept.  of  Agricul., 
Bureau  of  Chemistry,  Bulletin  No.  126, 
July  3,  1909). 

MODES  OF  ADMINISTRA- 
TION.— Acetanilide  is  insoluble  in 
glycerin,  slightly  soluble  in  water  (1 
grain  in  3  fluidrams  of  cold,  and  1 
grain  in  18  minims  of  hot,  water), 
but  completely  so  in  alcohol  (1 
grain  in  2^^  minims),  and  readily  in 
ether  (1  grain  in  18  minims).  It  is 
readily  suspended  in  syrupy  mixtures 
and  can  be  given  with  most  drugs 
thus  administered.  Acetanilide  is 
also  dispensed  by  druggists  in  the 
form  of  tablets,  which  are  quite  taste- 


less when  taken  with  a  mouthful 
of  water.  It  may  be  given  in  the 
form  of  powders  or  in  dilute  alcoholic 
solutions. 

There  is  also  available  the  official 
compound  acetanilide  powder  {^pul- 
vis  acetanilidi  compo  situs),  contain- 
ing acetanilide,  7  parts;  caffeine,  1 
part,  and  sodium  bicarbonate  (to  in- 
crease the  solubility  of  the  acetani- 
lide), 2  parts,  the  dose  of  which  is  5 
to  10  grains  (0.3  to  0.6  Gm.). 

While  acetanilide  is  not  soluble  and 
is  readily  suspended  in  syrupy  mixtures, 
it  can  be  combined  with  ammonia  in 
any  of  its  forms,  salicylic  acid,  nux 
vomica,  digitalis,  codeine,  creosote,  po- 
tassium bromide,  etc.  A  prescription 
can  therefore  be  elaborated  that  can 
be  much  more  accurately  adapted  to  the 
case  in  hand  than  any  of  the  ready- 
made  combinations.  The  foundation  of 
most  of  the  coal-tar  product  combina- 
tions is  acetanilide,  which  has  been  com- 
bined with  bicarbonate  of  soda,  caffeine, 
carbonate  of  ammonia,  etc.  The  com- 
bination may  be  chemical  or  mechanical, 
it  matters  little  which,  as  it  is  practically 
broken  up  in  the  body  into  acetanilide 
radicals  and  other  constituents.  L.  Fau- 
geres  Bishop  (Med.  News,  June  10, 
1899). 

Various  combinations  of  acetanilide 
with  other  drugs  (adjuvants  and  corri- 
^ents)  may  be  made  to  meet  the  exi- 
gencies of  practice,  some  of  which  are 
as  follows : — 

B  AcetaniUdi^ gr.  xij  (0.800). 

Caffeince  citratce  ....   gr.  iij    (0.200). 
CamphorcE  mouo- 

brom gr.  vj    (0.400). 

Misce  et  fiant  capsulse  no.  vj. 

Note. — The  caffeine  and  camphor  are 
used  as  corrigents  to  the  acetanilide. 

B  Acetanilidi    gr.  xv  (1.000). 

Sodii  bicarbonatis   ..   gr.  x     (0.650). 

Ammonii  carbonatis.  gr.  xv  (1.000). 
Misce  et  fiant  capsulse  (not  pulveres) 
no.  x. 

Note. — The  sodium  bicarbonate  aids 
in  the  assimilation  of  the  acetanilide, 
while  the  ammonium  carbonate  acts  as 
a  corrigent. 


ACETANILIDE    (SAJOUS). 


215 


T}.  .■Iccfaiiilidi gr.  XX      (1.300). 

Sodii  bicarboiiatis.  gr.  xv      (1.000). 

Caffcimc  gr.  vj       (0.400). 

Acidi  citrici   gr.  x        (0.650). 

Misce  et  fiant  capsulne  (not  pulvcrcs) 
no.  X. 

Note. — The  caffeine  and  citric  acid  in 
the  above  should  be  mixed  and  slightly- 
moistened;  this  allows  the  formation  of 
a  fresh  preparation  of  citrated  caffeine ; 
it  should  then  be  dried  and  mixed  with 
the  other  ingredients. 

B  AcefanUidi gr.  xx      (1.300). 

Sodii  bicarboiiatis.  gr.  xx  (1.300). 
Sodii   salicylatis    .    Siss  (6.000). 

Misce  et  fiant  chartulje  no.  x. 
Note. — The  sodium  salicylate  is  used 
as  a  synergist  to  the  acetanilide. 

^  Acetanilidi gr.  xx      (1.300). 

Potassii  broiiiidi   .    gr.  xxx   (2.000). 
Sacchari  lactis  ...    gr.  xv      (1.000). 
Misce  et  fiant  chartulas  no.  vj. 
Note. — The    potassium    bromide    is 
used  as  a  synergist  to  the  acetanilide. 

I^.  Acetanilidi gr.  xxv    (1.600). 

Potassii  broinidi  .  gr.  xv  (1.000). 
Caffeincc  cit rates  .  gr.  v  (0.325). 
Misce  et  fiant  capsulas  no.  x. 

B.  Acetanilidi gr.  xxv    (1.600). 

Sodii  bicarboiiatis.  gr.  x        (0.650). 
CaffeincB   citrafce    .    gr.  vj       (0.400). 
Caiiiplwro'      mono- 
bromated    gr.  vj       (0.400). 

Misce  et  fiant  capsulse  no.  x. 

IJ  Acetanilidi gr.  x        (0.650). 

Sodii  bromidi gr.  L        (3.250). 

Extracti  hyoscy- 

ami  gr.  v        (0.325). 

Caffeiiice  citratce    .    gr.  v        (0.325). 
AIorpliiiicesnlphatis.gr.  %       (0.013). 
Misce   et  fiant  tabellae    (or   capsulas) 
no.  X. 

Note. — The  sodium  bromide,  extract 
of  hyoscyamus,  and  morphine  sulphate 
all  act  as  synergists  to  the  acetanilide, 
while  the  caffeine  corrects  their  action. 

B  Acetanilidi gr.  xx      (1.300). 

Quinincc sulphatis  gr.  xx  (1.300). 
Extracti  Jiyoscy- 

ami  gr.  v        (0.325). 

Extracti  cannabis 

Ind gr.  iiss    (0.163). 

Arseni  trioxidi    ..    gr.  %o     (0.0065). 
Strvchnince  sul- 
phatis    gr.  %       (0.013). 

Misce  et  fiant  tabellas  (or  capsulse) 
no.  x. 

Note. — The  strychnine  sulphate  is 
used  instead  of  the  caffeine  as  a  cor- 
rigent. 


B  Acetanilidi Sj     (4.000). 

Ziiici  oxidi   3j     (4.000). 

Amyli q.  s.  ad  l]   (32.000). 

Misce  et  fiat  pulvis. 

Sig. :     Use  as  a  dusting  powder. 

T^  Acetanilidi 3j     (4.000). 

Adipis  lance  3ij    (8.000). 

Petrolati   ..q,  s.  ad  §j   (32.000). 
Misce  et  fiat  unguentum. 

IJ  Antipyrince   3j  (4.000). 

Caffeines  citratce  ..  gr.  xx      (1.300). 
Aquce    destillatce    .    iSiv       (120.000). 
Misce  et  fiat  solutio. 
Sig. :    Teaspoonful  as  required. 

Note. — In  the  above  prescription  anti- 
pyrin  is  used,  as  it  is  very  soluble,  while 
acetanilide  is  almost  insoluble.  W.  H. 
Foreman  and  J.  H.  Gertler  (Jour.  In- 
diana State  Med.  Assoc,  June  15,  1909) . 

It  has  been  supposed  that  the  addi- 
tion of  caffeine  to  acetanilide  decreased 
its  toxicity,  and,  therefore,  the  likeli- 
hood of  untoward  effects.  Hale  has 
shown  experimentally,  however,  that 
such  was  not  the  case,  and,  indeed,  that 
it  greatly  increased  it.  Sodium  bicar- 
bonate, on  the  other  hand,  tends  to  les- 
sen the  toxic  effects  of  acetanilide  upon 
the  heart. 

By  experiments  on  the  hearts  of 
warm-  and  cold-  blooded  animals  the 
writer  found  caffeine  of  little  or  no 
benefit  in  acetanilide  poisoning  in  so  far 
as  the  cardiac  energy  and  the  blood- 
pressure  were  concerned,  and  that  it 
apparently  exerts  a  harmful  effect  in 
some  cases.  But  there  appeared,  espe- 
cially in  the  dog,  to  be  a  well-established 
antagonism  on  the  heart  rate  which, 
however,  would  probably  be  insufficient 
to  be  of  any  value  in  cases  of  poisoning 
in  man.  Feeding  experiments  demon- 
strated the  absence  of  antagonism  be- 
tween acetanilide  and  caffeine,  in  all 
cases  the  addition  of  the  latter  drug 
causing  death  more  quickly  or  with  a 
smaller  dose.  This,  in  connection  with 
the  imperfect  antagonism  to  the  heart 
action,  makes  the  use  of  caffeine  in 
acetanilide  mixtures  especially  question- 
able. Sodium  bicarbonate,  in  contrast, 
lessens  the  toxicity  of  acetanilide,  both 


216 


ACETANILIDE    (SAJOUS). 


in  its  action  on  the  heart  and  on  the 
intact  animal,  increasing  the  duration 
of  life  or  making  the  use  of  a  larger 
dose  of  acetanilide  necessary  to  cause 
death.  Hale  (Jour,  of  Pharmacol,  and 
Exper.  Therap.,  Aug.,  1909). 

INCOMPATIBLES.—  Acetanilide 
forms  insoluble  compounds  with  the 
bromides  and  iodides  in  aqueous  solu- 
tion, and  a  soft  mass  on  trituration 
with  chloral,  carbolic  acid,  thymol,  or 
resorcinol.  According-  to  Blackwood, 
unexpected  and  often  alarming  effects 
are  observed  when  calomel  is  given 
with  any  coal-tar  product. 

CONTRAINDICATIONS.  —  Ace- 
tanilide should  not  be  used  when  the 
heart  is  fatty,  weak,  or  enlarged ;  in 
blood  disorders  such  as  pernicious 
anaemia  characterized  by  cell  destruc- 
tion ;  in  phthisis  or  other  exhausting 
diseases,  and  in  pregnant  or  nursing 
women. 

It  has  been  urged  against  the  coal-tar 
derivatives  that,  although  they  relieve 
pain,  they  do  not  procure  sleep.  In  the 
first  place  this  is  an  error;  they  do  in- 
duce somnolence,  though  this  is  much 
less  marked  than  when  opiates  are  used. 
But  even  were  it  true, — nothing  pre- 
vents the  simultaneous  use  of  safe 
soporifics,  such  as  the  bromides  or 
chloral  hydrate.  There  is,  in  fact,  a 
distinct  advantage  in  their  employment 
concomitantly,  since  the  dose  of  either 
agent — acetanilide  and  ammonium 
bromide,  let  us  say — can  be  made 
smaller,  2  grains  of  the  former  and  10 
of  the  latter  being  quite  sufficient  in 
most  cases  to  relieve  pain  and  insure 
prolonged  sleep.  Antipyrin  and  phe- 
nacetin  are  quite  as  efficient  when 
thus  administered,  but  somewhat 
larger  doses,  4  grains,  are  needed. 
Though  acetanilide  is  not  soluble  in 
water,  it  is  readily  suspended  in 
syrupy  mixtures,  which  will  also  take 
up  ammonivim  bromide  very  readily. 

Far  from  being  harmful,  in  the  hands 
of  the  profession,  the  coal-tar  deriva- 
tives have  furnished  us  the  only  means 


to  avoid  the  use  of  the  opiates  which, 
notwithstanding  the  great  service  they 
have  rendered  humanity,  have  left  in 
their  train  victims  in  numbers  untold, 
and  the  shadows  of  which  hover  at  once 
before  the  modern  practitioner's  mind 
when  he  is  called  upon  to  alleviate 
suffering.  Sajous  (Monthly  Cyclo.  and 
Med.  Bull,  March,  1910). 

PHYSIOLOGICAL     ACTION.— 

As  Antipyretic.-— In  the  normal  sub- 
ject, the  temperature,  according  to 
Nothnagel  and  Rossbach  and  most 
authorities,  is  lowered  only  when 
toxic  doses  are  given.  _  Not  so,  how- 
ever, when  fcA^er  is  present.  Here  a 
small  dose  suffices  to  produce  a 
marked  fall.  Dujardin-Beaumetz,  for 
example,  witnessed  a  decline  of  3°  C. 
(5.4°  F.)  and  cyanosis  in  a  case  of 
typhoid  fever  in  which  7^  grains 
(0.5  Gm.)  had  been  administered. 
Manquat  states  that  1^^  to  3  grains 
(0.1  to  0.2  Gm.)  suffice  to  influence 
the  temperature,  acetanilide,  accord- 
ing to  Krieger,  Cahn  and  Hepp,  being 
far  more  active  in  this  particular  than 
antipyrine.  Sweating  and  chills  are 
occasionally  observed. 

The  investigations  of  Hare  •  and 
Evans  suggested  that  the  fall  of  tem- 
perature produced  in  febrile  cases  was 
due  to  a  decreased  heat-production 
and  increased  heat-dissipation.  But 
Wood,  having  found  that  the  rectal 
temperature  not  only  did  not  fall  as 
did  that  of  the  surface,  but  that  it 
rose,  concludes  that  the  experiments 
of  Hare  and  Evans  "cannot  be  used  to 
explain  how  antifebrin  reduces  the 
.temperature."  Moreover,  most  Euro- 
pean investigators,  Lepine,  Podanow- 
sky  and  others,  hold  that  acetanilide 
acts  by  depressing  the  heat-center. 
According  to  Cushny,  it  affects  the 
nervous  heat-regulating  mechanism 
in  such  a  manner  as  to  lower  the  level 


ACETANILIDE    (SAJOUS). 


217 


at  which  the  bod3^-temperature  is 
maintained,  the  loss  of  heat  necessary 
to  produce  the  fall  in  temperature  be- 
ing accomplished  by  dilatation  of  the 
cutaneous  vessels.  The  manner  in 
which  acetanilide  acts  as  an  anti- 
pyretic is  stated  by  Butler  to  be  far 
from  understood. 

[The  antipyretic  action  of  acetanilide  be- 
comes plain  when  new  factors,  brought  out 
by  ni}^  own  labors,  are  also  taken  into  ac- 
count. The  adrenal  and  thyroid  secretions 
(see  "Internal  Secretions,"  p.  1008)  are  the 
blood  constituents  which  sustain  general  oxi- 
dation and  metabolism.  As  the  blood  enters 
all  tissues  through  their  arterioles,  constric- 
tion of  these  minute  vessels  must  necessarily 
reduce  the  quantity  of  blood  admitted  into 
the  tissues,  and  thus  inhibit  oxidation,  i.e., 
heat  production.  This  is  precisely  what 
acetanilide  brings  about  by  exciting  directly 
the  sympathetic  center,  which,  as  I  have 
shown  (loc.  cit.,  p.  982),  governs  the  caliber 
of  the  arterioles. 

This  mechanism  explains,  moreover,  all 
the  above  experimental  and  clinical  data.  A 
small  dose  suffices  to  reduce  fever,  though  in- 
active in  the  normal  subject,  for  example, 
because  the  sympathetic  center  is  already, 
during  fever,  the  seat  of  undue  metabolism 
and,  therefore,  oversensitive;  cyanosis  is  pro- 
duced by  large  doses  because  they  constrict 
abnormally  the  arterioles  and  cause  local  ac- 
cumulation of  CO2 ;  chills  are  excited  by 
lowering  of  the  surface  temperature  caused 
by  the  deficient  supply  of  arterial  blood  in- 
cident upon  the  constriction  of  the  arterioles, 
etc.     C.  E.  DE  M.  S.] 

Action  as  Analgesic. — According  to 
the  prevailing  view,  acetanilide  acts 
directly  as  a  sedative  upon  the  nerv- 
ous system,  especially  upon  the  sen- 
sory portion  of  the  spinal  cord;  with 
toxic  doses  the  effect  may  extend  to 
total  loss  of  reflex  action  and  sensory 
and  motor  paralysis,  the  muscles  be- 
ing influenced  only  directly.  Wood 
holds  that,  "directly  or  indirectly,  ace- 
tanilide affects  the  cerebral  function," 
though  at  a  certain  stage  of  its  toxic 


action  consciousness  may  be  uninflu- 
enced while  the  rest  of  the  nervous 
system  is  clearly  affected.  Bokai 
ascribes  the  effects  of  acetanilide  to 
paralysis  of  the  motor  nerve-endings 
in  the  muscles,  sufficiently  prolonged 
exposure  of  the  latter  to  the  poison 
also  annulling  their  ability  to  con- 
tract. Cushn}^,  referring  to  this  and 
other  coal-tar  products,  states  that 
"by  man}^  they  are  supposed  to  have 
a  sedative  or  depressant  effect  on 
the  nervous  system."  The  analgesic 
action  of  acetanilide  is  generally  as- 
cribed to  this  supposed  sedative 
eft'ect,  though  all  agree  that  applied 
locally  to  the  tissues  it  acts  as  a 
stimulant  or  mild  irritant. 

[These  various  opinions  involve  the  as- 
sumption that  a  dose  of  acetanilide  dissolved 
in  the  thirteen  pints  of  blood  the  vessels  of 
an  adult  contain  will  make  a  sufficiently 
strong  solution  to  act  directly  on  the  central 
or  peripheral  sensory  elements.  Clinically 
such  a  solution  in  water,  when  injected  di- 
rectly into  the  tissues,  has  no  local  effect 
other  than  that  produced  by  water  without 
acetanilide.  The  above  explanations  have, 
therefore,  no  foundation  in  fact. 

On  the  other  hand,  the  analgesic  action 
of  acetanilide  is  clearly  explained  by  the 
mode  of  action  I  have  pointed  out :  By  ex- 
citing the  sympathetic  center,  it  causes  con- 
striction of  all  arterioles,  and,  by  thus  reduc- 
ing the  volume  of  blood  admitted  into  the 
diseased  area,  it  counteracts  the  cause  of  the 
pain  therein — the  hyperemia.     C.  E.  de  M.  S.] 

Action  on  the  Blood. — The  cyanosis 
produced  by  excessive  doses  of  ace- 
tanilide is  ascribed  by  Lepine,  He- 
nocque  and  others  to  transformation 
of  the  hemoglobin  into  methemoglo- 
bin,  and  by  Vierordt,  Halliday  and 
others  to  the  reduced  haemoglobin  as 
it  occurs  in  venous  blood.  Some  con- 
tend that  the  red  corpuscles  are  dis- 
organized, while  others  hold  that  they 
remain  intact. 


218 


ACETANILIDE    (SAJOUS). 


[AA'hen  the  dose  is  excessive  or  from  one 
cause  or  another  the  sympathetic  center  is 
oversensitive,  the  arterioles  are  so  constricted 
that  the  volume  of  blood  admitted  into  the 
tissues  is  inadequate.  The  oxygen  supply 
being  deficient  in  proportion,  the  blood  be- 
comes venous  prematurely  and  cyanosis  en- 
sues. When  still  further  reduced  the  hemo- 
globin breaks  down  and  methemoglobin  ap- 
pears in  the  blood. 

The  view  of  Vierordt  and  others  that  the 
cyanosis  is  due  to  reduced  hemoglobin  is 
thus  sustained.  But  this  applies  as  well  to 
methemoglobinemia,  since,  as  I  have  shown 
(see  "Internal  Secretions,"  3d  ed.,  pp.  102 
and  828),  this  phenomenon  is  produced  when 
the  connecting  link  between  the  hematin  and 
the  albuminous  constituent,  the  oxygen-laden 
adrenal  secretion,  is  taken  up  by  a  powerful 
reducing  agent — the  tissues  in  the  present  in- 
stance.    C.  E.  DE  M.  S.] 

Action  on  the  Circulation. — Injec- 
tions of  acetanilide  in  animals  have 
been  found  to  cause  at  lirst  a  slight 
increase  in  the  number  and  force  of 
the  heart-beats,  with  corresponding- 
rise  of  blood-pressure.  Later,  and 
also  from  the  first  with  larger  doses, 
circulatory  depression  is  observed. 
In  febrile  patients  the  lowering  of 
temperature  produced  by  the  drug  is 
often  accompanied  by  reduction  in 
the  frequency  and  size  of  the  pulse. 
Large  doses  are  said  to  depress  the 
heart  directl}'-. 

[These  phenomena  are  the  normal  results 
of  the  exciting  action  of  the  drug  upon  the 
sympathetic  center  and  the  resulting  con- 
striction of  the  arterioles.  Those  of  the 
heart  admitting  less  blood  into  its  muscular 
walls,  the  force  of  its  contractions  and 
their  number  are  reduced.  The  heart's 
action  may  be  arrested  by  the  same  process. 
C.  E.  DE  M.  S.] 

UNTOWARD  EFFECTS  AND 
ACUTE  POISONING.— The  symp- 
toms of  poisoning  include  primarily 
the  cyanosis,  which  begins  at  the  lips 
and  then  extends,  gradually  becoming 
more  intense,  over  the  face  and  the 


rest  of  the  body,  and  is  accompanied 
by  profuse  sweating  and  prostration. 
In  some  cases  there  is  ashen  lividity 
and  the  temperature  falls  rapidly  to 
95°  F.  or  lower.  The  pupils  are 
dilated  and  fixed.  The  respiration  is 
slow  and  shallow,  and  the  pulse  be- 
comes steadily  weaker  and  then  irreg- 
ular and  fluttering.  Somnolence,  un- 
consciousness and  coma,  and  cardiac 
arrest  follow.  In  some  instances 
sudden  heart-failure  occurs  soon  after 
the  onset  of  the  symptoms,  the  organ 
being  arrested  in  diastole.  Erythem- 
atous or  urticarial  skin  eruptions 
and  disorders  of  hearing  are  occasion- 
ally observed. 

[Acetanilide  proves  toxic,  from  my  view- 
point, when  it  causes  sufficient  constriction 
of  the  arterioles  (by  exciting  the  sympa- 
thetic center")  to  prevent  the  entrance  of 
blood  into  the  tissue  capillaries,  thus  ar- 
resting function.  As  the  vascular  constric- 
tion increases,  cyanosis  deepens,  and  the 
skin  becomes  livid ;  the  spiral  muscles  of  the 
sweat-glands  being  deprived  of  blood,  they 
are  relaxed,  and  profuse  sweating  occurs; 
the  pupillary  sphincters  being  relaxed  through 
the  same  process,  the  pupils  dilate.  The  fail- 
ure of  the  skeletal  muscles  to  receive  blood 
accounts  for  the  prostration,  while  a  similar 
deficiency  of  blood  in  the  myocardium  ex- 
plains the  weakening  pulse  and  the  cardiac 
arrest  in  diastole.  The  cerebral  ischemia 
being  no  less  complete,  somnolence,  uncon- 
sciousness and  coma  occur  in  more  or  less 
rapid  succession. 

The  occasional  presence  of  deafness  is  due 
to  the  inadequate  supply  of  blood  to  the  aural 
apparatus  that  results  from  undue  constric- 
tion of  the  arterioles.  The  same  process  ex- 
plains the  cutaneous  eruptions,  since  the 
slowing  of  the  blood-stream  in  the  tissues 
interferes  with  the  carrying  ofif  of  waste 
products  from  the  skin.     C.  E.  de  M..  S.] 

Case  of  a  man,  aged  45,  suffering 
from  a  form  of  intermittent  fever.  The 
patient  complained  of  almost  unbearable 
headache;  pulse,  120;  respirations,  23; 
temperature,  104.8°  F.  Ten  grains  of 
acetanilide  were  given,  and  about  twenty 


ACETANILIDE    (SAJOUS).  219 

minutes  later  the  patient  said  his  head-  The  character  of  these   cases   and  the 

ache    was    relieved,    and    that    he    felt  doses  used  were  as  follows : — 

easier.     About   forty-five  minutes  after  t,„^„ „.    /  ,  .,,>      r^     t,  k         • 

.  •'.  Pneumonia  (child). .  .One-half    grain     every    2 

the  drug  was  administered  all  sweating  hours  until  2   grains 

t            J                      1-                     1.-             c  ■                                                       were  taken. 

ceased,    and    a    peculiar    sensation    of  Capillary  bronchitis 

warmth  under  the  skin  was  complained  ^'^^'''^^ ^'^"'^11  doses  frequently 

repeated. 

of.      To    this,    in    twelve   or    fifteen    mm-  Capillary  bronchitis 

,                         J  r     1     •    J.              -i.  1  •               u-i  (child) Small  doses  frequently 

utes,  was  added   intense   itching,   while  repeated. 

in  three  or  four  minutes  the  whole  body  Typhoid Five  grains  every  4  hours 

presented  a  general  erythematous  con-  Headache About  20  grains. 

,.^.              rr-,              .■                r                          c  Headache Thirty  grains  (?). 

dition.     The    entire   surface   was   of    a  M^o^a^vio                  "o         •     >>*  i       r     t 

irleadacne Orangeine     taken  freely 

brighter  red   than   that  of  a  typical   case  Headache Thirteen  or  fourteen  5-grain 

of  scarlet  fever,  and,  like  the  scarlatina  <i°ses  in  12  hours. 

,      .,     ,.                     ,                                 ,  Headache Bromoseltzer. 

rash,  It  disappeared  on  pressure,  to  re-  Neuralgia Dose  not  given. 

turn   as   soon   as   pressure   was   removed.  Neuralgia  of  heart... Five  5-grain   doses   in   5 

No  part  of  the  body  was  exempt  from  hours. 

.,  .            1      .1               •         i-               1            r  it.  Burn Boroacetanilide    applied 

this  rash,  the  conjunctivae,  palms  of  the  freely. 

hands  and  soles  of  the   feet  being  as  red  Bum  (infant) Acetanilide  applied  freely 

,       J-   .L      v    J          nru      i.   to  umbilical  cord. 

as  any  part  of  the  body.     The  tempera-  Headache Excessive  doses  of  "bromo- 

ture    of   the    surface    seemed    elevated,  seltzer." 

but    the    thermometer     in    the     mouth  Typhoid  (child) Five  grains. 

,            1    i.1,    i.    v                       J      11       f   ii; Typhoid  (child) Dose  not  given. 

showed  that    it   was    gradually    falling.  ^^,^,    ;„  /  u■^^\           /-,          .,         ,,  ,^ 

°   .             •'                °  Malaria  (child) One  and  one-half  grams. 

The  body  appeared  as  if  every   super-  t^  i  r       -mt                 i  t^         /tt  ^  ^^ 

r  ■  i        M,                 JM  .  J  Kebler.  Morgan  and  Rupp  (U.  S.  Dept 

ncial  capillary  was  dilated.  r   a      •     i     d                r  ^,       ■           ^ 

iir-.i.  xu                             r  xu          I,  .1-  °f  AgricuL,  Bureau  of  Chemistry,  Bui 

With  the  appearance  of  the  rash  the  ,  ,.     t.^      ioa    t  .      o    i<^«^n 

■^  u-      u                       •  X           xt,        X-     ^  '^tin  No.   126,  July  3,   1909). 
itching  became  more  intense,  the  patient 

assuming    all    positions    possible    while  tu^    ^,-^^<-    *^^;      -j.         r           i 

.  u-          ^ir-.-L.-      ..t,         X        1  ^'^^  great  majority  of  such   cases 

scratching.      Within    the    external    ear  ,             .           .        . 

the  itching  was  especially  intense,  but  ^^^  ^^^  ^^  ^toxication  by  proprietary 

.     there  was  no  disturbance  of  hearing,  headache  powders  sold  under  a  vari- 

The  rash  lasted  for  six  hours,  without  ety  of  fancy  names.     Proprietary  prep- 

any  apparent  change,  and  then  disap-  arations  containing  acetanilide  were  re- 

peared    rapidly    from    all   parts    of   the  ^   j     .       i            i                    ,    .       ^« 

r  J      •      u           1         A        ^^          u  ported   to   have   been    used   in   77,   or 

body   simultaneously,    and    as  the    rash  ^^  r                                           o         ^      /  /  ,    wi 

faded  the  itching  subsided.    About  this  ^^.S    per    cent.,    of    the    614    cases    of 

time  a   slight  cardiac   irregularity   be-  poisoning  mentioned  above  by  Kebler, 

came  evident,  and  this  lasted  for  four  Morgan,  and  Rupp.      It  is  well  known 

days.     The  only  drug  taken  before  the  that      certain      individuals      show     an 

acetanilide  was  a  single  dose  of  calomel  •■,•                               ,       ,                  ,  . 

(about  5  grains).    P.  V.  Ballon  (Med.  jdiosyncrasy  to  the  drug,  and  in  some 

News,  Jan.  18,  1898).  instances  very  small  doses  will  suffice 

_,  .  to  cause  death.. 
[The  two  unusual  symptoms,  intense  itch- 
ing and  general  erythema,  were  due  to  ex-  ^^^^  °^  acetanilide  poisoning  in  a 
cessive  dilatation  of  the  arterioles  after  the  woman,  aged  26  years,  who  had  taken 
true  toxic  efifects  had  passed  off,  the  violent  ^  ^'■^'"^-  Collapse  with  strong  con- 
excitation  to  which  the  poison  had  subjected  vulsive  movements,  partial  loss  of 
the  sympathetic  center  having  temporarily  consciousness,  and  great  retching, 
exhausted  it.     C.  E.  de  M.  S.]  Whisky,  strychnine  nitrate,  and— for 

two    hours — artificial    respiration    in- 

Out   of  288  practitioners   questioned,  duced     recovery.       O.     R.     Summers 

219,   or   76   per   cent.,    stated  that   they  (N.  Y.  Med.  Jour.,  March  24,  1900). 

had    observed    instances    of    poisoning  Case    of    fatal    acetanilide    poisoning, 

following  the  use  of  acetanilide.    These  The   patient,   a   man   of   37,   had  taken 

219  observers  report  614  cases  of  poison-  six  "headache  powders"  each  containing 

ing,  including  17  deaths,  i.e.,  2.7  per  cent.  10  grains.     He  became  delirious,  com- 


220 


ACETANILIDE    (SAJOUS). 


plained  of  abdominal  pain,  vomited, 
and  was  slightly  jaundiced.  His  tem- 
perature rose  to  100.2°  F.,  the  lips  and 
nails  became  intensely  cyanotic,  respira- 
tions shallow  and  frequent.  The  urine, 
of  which  10  ounces  were  passed  on  ad- 
mission, was  nearly  black  and  strongly 
alkaline.  Anuria  occurred,  and  six  days 
later  the  man  died.  There  was  alter- 
nate constipation  and  diarrhea,  and 
fortj^-eight  hours  before  death  the  feces 
constantly  showed  blood-pigment,  blood- 
clots,  and  corpuscles.  Philip  Brown 
(Amer.  Jour.  Med.  Sci.,  Dec,  1901). 

Case  of  acetanilide  poisoning  with 
fatal  results  following  the  ingestion  of 
bromoseltzer  taken  to  relieve  a  headache. 
The  heart,  already  weakened  from  re- 
peated doses  of  the  drug,  was  unable 
to  stand  a  slight  overdose  and  the  vic- 
tim died  in  a  few  hours.  H.  B.  Hem- 
enway  (Jour.  Amer.  Med.  Assoc,  Dec. 
29,  1906). 

Personal  case  in  which  the  patient  had 
taken  four  headache  powders..  These 
had  been  taken  each  hour  between  nine 
and  noon.  The  surface  of  the  body 
presented  an  ashen-gray  appearance,  the 
mucous  membranes  having  a  much 
darker  hue.  The  temperature  was  96 
degrees ;  pulse,  60,  and  respiration,  10. 
Digitalis,  strychnine,  and  alcohol 
baths  with  friction  were  employed, 
with  dry  heat  to  the  surface.  When 
the  patient  was  able  to  swallow,  a 
combination  of  aromatic  spirit  of  am- 
monia, brandy,  and  capsicum  was 
given.  Twenty-four  hours  later  the 
temperature  was  slightly  subnormal, 
the  dusky  appearance  of  the  face  dis- 
appeared to  a  large  extent,  but  the 
symptoms  of  cyanosis  did  not  wholly 
vanish  until  the  second  day.  The  pow- 
ders contained  3  grains  of  acetanilide, 
2  grains  of  bicarbonate  of  sodium,  and 
1  grain  of  caffeine ;  hence  the  total  dose 
was  12  grains  of  acetanilide.  Earps 
(Merck's  Archives,  June,  1901). 
The  doses  capable  of  producing  toxic 
efifects  are  sometimes  very  small,  but 
it  is  probable  that  some  of  the  drugs 
recommended  in  textbooks  for  the 
treatment  of  poisoning  by  coal-tar 
products,    strychnine    and    belladonna, 


for  example,  do  more  harm  than  good, 
and  that  small  doses  may  thus  prove 
fatal  through  the  toxicity  added  to 
theirs  by  the  supposed  antidotes  or 
remedial  measures. 

Case   of   poisoning   in   a   man   of   29 
years   after  taking   within   three   hours 
three  powders  containing  each  2^/^  grains 
of  acetanilide.     It  proved  fatal  notwith- 
standing the  use  of  ^o  grain  of  strych- 
nine  (with  ^^0  grain  atropine  sulphate) 
repeated   in   less   than   two   hours   with 
VaO  grain  digitalin  and  %oo  grain  nitro- 
glycerin,  all   given    subcutaneously,  be- 
sides  20    drops    of    spirit    of    camphor 
and    a    teaspoon ful    of    whisky    every 
hour  and  a  hot  pack,  with  feet  elevated, 
and    cold   to   the   head.     The  terminal 
symptoms   were   deep   cyanosis,   a   very 
weak    pulse,    a    convulsion    lasting    ten 
minutes,  and  pulmonary  edema,  the  lat- 
ter being  verified  at  the  autopsy.     A.  L. 
Smedley     (Jour.    Amer.    Med.    Assoc, 
Apr.  27,  1907). 
[It  is   a  question   whether  large   doses   of 
strychnine  usually  given  are  not  more  harm- 
ful than  beneficial   in  these  cases.     It  raises 
powerfully    the    blood-pressure    by    exciting 
the  vasomotor  center.     It  would  thus  prove 
helpful   by   forcing   arterial   blood    from   the 
deep  trunks  through  the   arterioles  into  the 
cyanotic  tissues  were   it  not  that,   as   is  the 
case    with    ergot,    the    arterioles,    owing    to 
their  diminutive  caliber,  are  the  most  affected 
by    the    vasomotor    constriction.      In    other 
words,  a  slight  constriction  hardly  influences 
a  large  vessel,  while  the  same  degree  of  con- 
striction   will    practically    close    up    a    very 
small  one.     Edema  of  the  lungs  may  occur 
under    these    circumstances    simply    because 
the   venous   stream    is   itself   blocked    (being 
unable    to    enter    the    arterial    system)     by 
arrest    of    the    arterial    circulation,    through 
the   excessive   constriction   of  the    arterioles. 
C.  E.  DE  M.  S.] 

When  a  large  dose  is  taken,  the 
symptoms  once  started  may  suddenly 
assume  marked  severity. 

Case  in  a  man  52  years  of  age  who 
suffered  from  severe  chronic  headache. 
Not  obtaining  relief  from  headache  pills 
and  powders  he  purchased  an  ounce  of 
acetanilide  in  bulk  and  took  a  half-t^a- 


ACETANILIDE    (SAJOUS). 


22i 


spoonful — about  30  grains.  The  head- 
ache disappeared  in  a  short  time,  and  he 
then  went  out  on  the  street.  While  walk- 
ing he  felt  weak.  He  then  went  to  a  bar- 
ber shop,  and  the  man  who  shaved  him 
noted  that  he  had  a  "terrible  blueness." 
He  then  entered  a  store,  where  in  a 
few  minutes  he  was  seen  to  sway  and 
fall  to  the  floor.  He  was  found  in  deep 
syncope,  extremely  cyanotic,  with  a 
feeble  and  rapid  pulse.  He  was  readily 
resuscitated,  but  in  a  few  minutes  there 
was  another  attack  of  syncope,  which 
was  repeated  a  number  of  times  during 
the  next  few  hours.  He  gradually  re- 
covered. J.  B.  Tyrrell  (Jour.  Amer. 
Med.  Assoc.',  Mar.  31,  1906). 

Poisoning  by  Absorption, — Acetan- 
ilide    having   been    recommended   as   a 
dressing  for  wounds,  burns,  and  super- 
ficial injuries  in  general,  many  cases  of 
poisoning  have  occurred  owing  to  the 
large  quantities  applied  to  the  lesions, 
and  the  ease  with  which  it  is  absorbed. 
Two  cases  also  emphasizing  the  neces- 
sity of  caution  even  when  using  acetani- 
lide  externally.     The  first  case  had  sus- 
tained   an    extensive   burn   of   the    left 
lower  extremity.    The  raw  surface  was 
covered    with    Thiersch's    skin    grafts 
taken  from  the  right  leg  and  thigh.    An 
assistant  dressed  the  right  limb.    Early 
the   next   morning  the   patient   became 
cyanotic,  collapsed,  and  became  uncon- 
scious.    It  was  learned  that  the   right 
leg    had    been    copiously    dusted    with 
acetanilide.     This  drug  has  no  place  in 
aseptic  cases,  while  in  septic  cases  more 
efficient  and  less  dangerous  agents  are 
available.     F.  T.   Stewart    (Phila.  Med. 
Jour.;  Merck's  Archives,  March,  1902). 
Two    cases    of    acetanilide    poisoning 
from  absorption  from  external  wounds 
in    children.      The   first   patient   was    a 
baby  six  weeks  old  who  had  a  trouble- 
some eczema  of-  the  buttocks.     A  pow- 
der was  applied  composed  of  equal  parts 
of  acetanilide  and  subgallate  of  bismuth. 
Twenty-four  hours  later  the  skin  of  the 
child  was  markedly  cyanotic,  the  tem- 
perature   was    subnormal,    the    respira- 
tions were  feeble  and  shallow,  the  pupils 
were  dilated,  the  heart  was  rapid  and 


weak,  and  extremities  cold.  Hot  ap- 
plications were  ordered,  with  the  in- 
ternal administration  of  whisky,  and 
at  the  end  of  three  days  all  symp- 
toms  of  poisoning  had   disappeared. 

A  second  case  was  that  of  a  child  of 
two  and  one-half  years  who  had  re- 
ceived a  severe  scald  of  the  buttocks. 
A  powder  composed 'of  equal  parts  of 
subnitrate  of  bismuth  and  acetanilide 
was  applied,  which  soon  relieved  the 
pain.  On  the  second  day  the  lips,  ears, 
and  finger-tips  were  blue.  The  symp- 
toms of  prostration  were  present  as  in 
the  first  case,  but  not  to  the  same  de- 
gree. The  blueness  gradually  disap- 
peared, and  at  the  end  of  a  week  the 
wound  was  healed.  J.  L.  Menasses 
(Inter.  Med.  Mag.,  May,  1901). 

Case  of  a  woman,  aged  37,  who  for 
the  last  eleven  months  had  applied 
acetanilide  powder  twice  daily  to  a  large 
and  deep  varicose  ulcer  on  the  leg.  She 
had  concealed  the  existence  of  this  ulcer 
from  her  attending  physician,  and  ap- 
plied the  powder  to  it  upon  the  advice 
of  a  friend.  Her  illness  had  begun 
eleven,  months  before  with  an  attack 
of  influenza,  which  was  followed  by 
"indigestion  and  kidney  trouble."  She 
then  became  troubled  with  nervousness, 
worried  about  trivial  things  and  com- 
plained of  headache  and  dizziness.  Later 
she  suffered  abdominal  pain,  dyspnea, 
nausea  and  occasionally  vomiting.  There 
was  marked  cyanosis,  the  conjunctivas 
being  bluish.  The  heart-sounds  were 
weak.  The  spleen  and  liver  were  not 
enlarged.  The  patient  lost  seventy 
pounds  in  the  eleven  months.  She  was 
sent  to  the  hospital,  with  a  diagnosis  of 
some  form  of  severe  anemia.  The 
urine  was  dark  amber.  The  blood  was 
also  dark  in  color,  flowed  slowly,  and 
coagulated  quickly.  Red  blood-cells 
numbered  4,370,000;  leucocytes  20,960; 
hemoglobin  53  per  cent.  There  were 
95.2  per  cent,  polymorphonuclears  and 
2.8  per  cent,  lymphocytes.  The  acetan- 
ilide was  withdrawn  and  the  patient 
given  Blaud's  pills  and  strychnine. 
One  week  later  her  color  and  heart- 
sounds  were  greatly  improved.  Blood- 
count  eleven  days  after  admissioi^ 
showed  red  cells  6,350,000,  leucocytes 


222 


ACETANILIDE    (SAJOUS). 


9920,  hemoglobin  63  per  cent.,  poly- 
morphonuclears 74.2  per  cent.,  and 
lymphocytes  13.8  per  cent.  R.  M. 
Goepp  (Jour.  Amer.  Med.  Assoc, 
Aug.  4,  1906). 

Treatment  of  Acute  Acetanilide 
Poisoning. — The  physiological  action 
of.  acetanilide  being  but  imperfectly 
known,  cases  of  intoxication  by  this 
drug  are  treated  on  general  principles, 
i.e.,  by  measures  thought  to  counter- 
act the  symptoms.  Cardiac,  respira- 
tory and  vasomotor  stimulants  are 
therefore  recommended.  Ether,  hy- 
podermically,  has  been  most  fre- 
quently used.  Belladonna  is  regarded 
as  the  best  drug  to  fulfill  the  indi- 
cations; it  tends  to  equalize  the 
blood-pressure,  especially  when  ex- 
ternal heat  is  applied  simultaneously. 
Brandy,  digitalis,  strychnine,  aro- 
matic spirits  of  ammonia  and  inhala- 
tions of  oxygen  have  all  been  recom- 
mended. Artificial  respiration  is  a 
valuable  adjuvant  to  any  treatment 
adopted. 

[In  the  light  of  my  views,  the  toxic  phe- 
nomena being  all  due  to  excitation  of  the 
sympathetic  center,  agents  which  depress 
this  center  are  indicated.  Ainyl  nitrite  in- 
halations, sustained  by  nitroglycerin  inter- 
nally or  hypodermically,  fulfill  this  role.  Arti- 
ficial respiration  is  important  to  insure 
prompt  oxygenation  of  the  blood  as  soon  as 
the. circulation  is  re-established.  Warm  (110'' 
F.)  saline  solution  intravenously,  or,  in  less 
urgent  cases,  per  rectum,  facilitates  excre- 
tion of  the  poison  and  prevents  its  irritat- 
ing action  on  the  sympathetic  center,  thereby 
hastening  recovery. 

Contraindicated.  ^ — Digitalis,  which,  like 
acetanilide,  though  less  actively,  excites  the 
sympathetic  center,  and  alcohol,  which,  by 
becoming  oxidized  in  the  blood,  favors  its 
conversion  into  venous  blood,  and,  therefore, 
cyanosis.  Large  doses  of  strychnine,  which, 
by  causing  excessive  vasoconstriction,  tend 
to  increase  the  constriction  of  the  arterioles 
caused  by  the  poison.     C.  E    de  M.   S.] 


CHRONIC  ACETANILIDE  POI- 
SONING.— The  symptoms  of  this 
condition  are :  cyanosis,  which  may  be 
extreme,  anemia  aiid  wasting.  The 
anemia  may  be  of  sudden  onset  and  is 
evidenced  by  a  distinct  leucocytosis, 
marked  reduction  in  the  hemoglobin 
percentage  and  in  the  number  of  red 
corpuscles,  some  of  which  show 
nuclei.  Other  common  symptoms  in- 
clude disordered  digestion,  enlarge- 
ment of  the  spleen  without  tender- 
ness, prostration,  weak  and  frequent 
pulse,  dyspnea,  excitability,  tremor, 
and  mental  aberration,  with  a  tend- 
ency to  deceive  in  denying  the  use  of 
the  drug.  The  urine  is  dark-colored. 
The  combination  of  warm  extremities 
with  marked  cyanosis  is  considered  a 
distinguishing  feature  of  poisoning  by 
acetanilide. 

The  blood  changes  above  men- 
tioned may  not  be  accompanied  by 
marked  impairment  of  health.  Ex- 
periments in  animals  have  shown  that 
the  prolonged  use  of  acetanilide  tends 
to  cause  fatty  degeneration  of  the 
heart,  liver,  and  kidneys. 

[The  continuous  use  of  acetanilide  by  per- 
petuating the  irritability  of  the  sympathetic 
center,  and  the  resulting  constriction  of  the 
arterioles  as  explained  in  preceding  com- 
mentaries, accounts  for  the  cutaneous  ische- 
mia, the  cyanosis,  the  general  prostration,  and 
for  the  rapid  and  feeble  heart  action.  The 
decrease  of  red  corpuscles  is  due  to  two  fac- 
tors :  (1)  breaking  of  the  hemoglobin  of  what 
corpuscles  reach  the  tissues  owing  to  the  de- 
oxidizing power  of  the  latter  (vide  supra), 
and  (2)  the  rapid  conversion,  on  this  ac- 
count, of  normal  corpuscles  into  worn-out 
cells.  This  in  turn  creates  a  need  for  an 
excess  of  phagocytes  ;  hence  the  leucocytosis, 
the  methemoglobinemia  and  the  immature 
red  corpuscles.     C.  E.  de  M.  S.] 

Case  in  which  the  most  striking  point 
was  the  good  general  condition  of  the 
patient.  Despite  the  intense  cyanosis 
and  the   easily  demonstrable  methemo- 


ACETANILIDE    (SAJOUS). 


223 


globineniia,  he  felt  and  seemed  prac- 
tically well  during  the  intervals  of  free- 
dom from  pain.  His  headache  tortured 
him,  but  the  methemoglobinemia  gave 
him  no  inconvenience  whatsoever.  There 
was  no  disturbance  of  respiration,  cir- 
culation or  any  other  symptom,  if  we 
except  the  slight  evidences  of  renal  ir- 
ritation which  were  present  from  time 
to  time.  R.  C.  Cabot  (Phila.  Med. 
Jour.,  Nov.  29,  1902). 

Case  of  a  woman  who  was  extremely 
nervous,  the  symptoms  accompanying 
an  artificial  menopause  brought  about 
by  the  removal  of  the  ovaries  for  per- 
sistent dysmenorrhea.  She  began  by 
taking  an  acetanilide  proprietary  remedy 
for  ovarian  pain,  and  soon  drifted  to 
acetanilide  because  it  was  cheaper.  She 
had  frequent  convulsive  attacks,  which 
were  of  a  character  that  led  to  the  diag- 
nosis of  uremia.  The  heart's  action 
was  weak  and  irregular ;  the  mucous 
membrane  of  the  mouth  of  the  vagina 
blue;  the  skin  and  conjunctivae  were 
white.  The  urine  had  a  low  specific 
gravity  and  a  large  quantity  of  albu- 
min. A  large  amount  of  acetanilide  was 
found  in  the  patient's  trunk.  This  being 
taken  away,  she  soon  manifested  the 
peculiar  traits  characteristic  of  drug 
habitues.  She  used  every  possible  means 
to  obtain  the  drug.  With  watching, 
rest,  and  tonics,  she  soon  began  to  im- 
prove, and  in  six  months  was  perfectly 
well.  Since  the  recovery  there  has 
been  no  inclination  to  return  to  the 
habit.  The  clinical  picture  in  this  case 
was  almost  typical  of  the  advanced 
stages  of  parenchymatous  nephritis.  T. 
W.  Luce  (Amer.  Med.,  Sept.  26,  1903). 

In  a  considerable  number  of  cases  of 
chronic  acetanilide  poisoning  studied, 
the  blood  picture  was  quite  character- 
istic. The  hemoglobin  cannot  be  esti- 
mated, on  account  of  the  presence  of 
methemoglobin,  which  gives  the  char- 
acteristic chocolate  color  to  the  blood. 
The  red  cells  are  usually  reduced  in 
number  and  are  more  or  less  deformed. 
There  is  usually  leucocytosis. 

In  cases  of  severe  chronic  poisoning 
by  acetanilide  and  related  coal-tar  prod- 
ucts, the  symptoms  are  usually  very 
similar  as  concerns  progressive  mental 


and  physical  debility,  which  later  often 
reaches  a  high  grade.  There  is  cardiac 
weakness,  with  more  or  less  pronounced 
cyanosis.  Apart  from  the  usual  choco- 
late hue  of  the  blood  so  noticeable  on 
puncture,  tlic  blood  picture,  were  it  not 
for  an  almost  invariably  present  leuco- 
cytosis, would  suggest  pernicious  ane- 
mia. D.  D.  Stewart  (Jour.  Amer.  Med. 
Assoc,  June  3,  1905). 

Case  of  a  man,  38  years  old,  mer- 
chant, who  consulted  the  author  on 
account  of  increasing  weakness,  nerv- 
ousness, and  shortness  of  breath.  At 
times  he  suffered  from  palpitation  of 
the  heart  and  throbbing  in  the  neck. 
There  was  blueness  of  the  lips,  face, 
and  finger-nails.  There  was  a  history 
of  neuralgia.  Heart  slightly  enlarged. 
No  murmurs.  The  urine  showed  indi- 
can  in  considerable  quantities.  The 
blood  was  practically  normal,  with  the 
exception  of  a  constant  polycythemia 
(6,000,000  red  blood  count).  At  first 
the  patient  would  not  admit  taking  any 
drug,  though  later  he  confessed  having 
used  a  patented  headache  powder  for 
some  months.  Withdrawal  of  the  drug 
and  general  tonic  treatment  restored 
him    to    health    in    about    six    months. 

Case  of  a  woman,  27  years  old, 
resembling  first  case  closely.  Here 
the  red  blood  count  was  always  under 
four  millions.  Stengel  (Jour.  Amer. 
Med.  Assoc,  July  22,  1905). 

The  almost  constant  manifestation  of 
chronic  acetanilide  poisoning:  (1)  cya- 
nosis that  may  be  extreme ;  (2)  more 
or  less  dyspnea  and  general  weakness, 
and  (3)  dark-colored  urine  that  con- 
tains paramidophenol  and  an  increased 
amount  of  the  ethereal  sulphates.  A 
most  striking  and  characteristic  con- 
dition is  the  anemia  of  the  second- 
ary type  with  degenerate  and  nucleated 
red  corpuscles.  Methemoglobin  may  be 
present  in  the  blood  and  in  the  urine. 
Dizziness,  syncopal  attacks,  tinnitus,  pal- 
pitation, may  be  pronounced  where  the 
anemia  is  advanced.  The  spleen  is 
often  enlarged.  Anorexia,  nausea,  vom- 
iting, and  diarrhea  may  occur.  Nervous- 
ness and  restlessness  are  aggravated  by 
the  removal  of  the  drug,  to  which  the 
patient   has   become   habituated.     J.    B. 


224 


ACETANILIDE    (SAJOUS). 


Herrick  and  E.  E.  Irons   (Jour.  Amcr. 
Med.  Assoc,  Feb.  3,  1906). 

Case  of  a  young  woman  who  had  per- 
sisted in  taking  some  coal-tar  prod- 
uct originally  prescribed  for  migraine. 
About  a  year  after  her  marriage  she 
died  suddenly  following  an  apparently 
normal  labor.  The  knowledge  of  the 
continued  use  of  the  prescription  during 
pregnancy  gave  the  clue  to  the  cause 
of  death.  A  great  danger  of  chronic 
poisoning  with  coal-tar  products  is  the 
sudden  yielding  of  the  heart  to  un- 
usual strain.  S.  Solis-Cohen  (Boston 
Med.  and  Surg.  Jour.,  Feb.  22,  1906). 

Case  of  chronic  acetanilide  poison- 
ing. The  patient  had  long  used 
acetanilide,  about  a  dozen  5-grain 
tablets  in  twelve  hours.  She  pro- 
cured 1000  at  a  time,  and  in  four 
years  had  used  several  thousand.  She 
suffered  from  severe  headaches  and 
vomiting  attacks  lasting  for  two  or 
three  days,  and,  as  a  rule,  she  would 
have  to  be  in  bed.  Two  years  earlier 
she  began  the  use  of  morphine  to- 
gether wdth  the  acetanilide  and  was 
using  as  much  as  2  grains  of  mor- 
phine a  day  to  get  relief.  When  first 
seen,  she  had  been  in  bed  for  six  weeks, 
was  emaciated,  no  appetite  on  account 
of  persistent  vomiting,  headache  always 
present;  slightly  jaundiced,  with  marked 
tenderness  and  dullness  over  the  gall- 
bladder region ;  very  constipated,  and 
suffering  from  tympanites.  Dr.  A.  F. 
Jonas  drained  the  gall-bladder  of  dark, 
thick,  stringy  bile.  She  made  a  good 
recovery  from  the  effects  of  the  opera- 
■  tion,  and  in  three  weeks  was  up  and 
around  a  little.  She  stopped  the  use  of 
any  drug  and  in  a  couple  of  months 
was  doing  her  work  and  feeling  well. 
About  a  year  and  a  half  later  suffered 
from  headache,  vertigo,  faintness,  tin- 
nitus, psychic  irritability,  dyspnea,  palpi- 
tation, and  edema,  with  tenderness  over 
the  gall-bladder  region;  large  quan- 
tities of  bile  and  mucus  were  being 
vomited.  She  was  using  coal-tar  prod- 
ucts and  morphine  to  relieve  the  pain. 
Her  lips  and  finger-nails  were  blue. 
She  had  lost  about  20  pounds  in  weight 
during  4  to  6  weeks.  Overgaard 
(Western  Med.  Rev.,  March,  1911). 


Treatment  of  Chronic  Acetanilide 
Poisoning. — Under  the  gradual  with- 
drawal of  the  drug",  strychnine  and 
digitalis,  these  cases  usually  recover 
promptly.  If  pains  and  insomnia 
occur,  codeine  may  be  used  tentatively 
lest  another  evil  habit  be  initiated. 
Constipation,  which  is  apt  to  follow 
for  a  time,  should  be  counteracted  by 
saline  aperients.  "  Sympathy  and  en- 
couragement are  potent  factors  for 
good  in  these  cases. 

[Here  both  strychnine  and  digitalis  are 
effective  because  they  counteract  not  the 
direct  action  of  the  acetanilide  on  the  sym- 
pathetic center,  but  the  exhaustion  of  this 
center.  Codeine  or  morphine,  admmistered 
with  due  caution,  are  effective  in  counteract- 
ing this  exhaustion,  since  they  also  act — from 
mj^  viewpoint — mainly  by  exciting  the  same 
center.     C.  E.  de  M.  S.] 

The  acetanilide — and  this  applies  to 
all  coal-tar  analgesics — habit  is  much 
more  easily  recovered  from  than  the 
opium  and  morphine  habits,  and  offers, 
therefore,  in  this  respect  a  marked  ad- 
vantage over  the  latter. 

The  treatment  is  comparatively  simple. 
With  gradual  withdrawal  of  the  drug, 
the  temporary  substitution  of  codeine 
to  relieve  pain,  and  the  use  of  tonics 
and  attention  to  the  stomach  and 
bowels,  recovery  will  usually  ensue. 
Watchfulness  against  relapse  is  neces- 
sary, but  the  habit  has  not  usually 
as  strong  a  hold  on  the  patient  as 
morphine  or  cocaine.  Even  in  the 
worst  cases  a  hopeful  prognosis  can 
•usually  be  given.  J.  B.  Herrick  and 
E.  E.  Irons  (Jour.  Amer.  Med.  Assoc, 
Feb.  3,  1906). 

Case  of  a  man,  aged  about  26, 
under  treatment  for  two  years  for 
syphilis,  who  had  taken  enormous  doses 
of  the  iodides.  He  had  sliffered 
greatly  from  headache  and  showed 
an  obscure  and  progressive  tendency 
to  cyanosis.  The  character  of  the 
latter,  with  the  cardiac  sj^mptoms  and 
splenic  enlargement,  led  to  the  diag- 
nosis of  acetanilide  poisoning.     It  was 


ACETANILIDE    (SAJOUS). 


225 


learned  that  the  patient  had  had  mi- 
graine previous  to  the  specific  infection 
and  formed  the  l<abit  of  taking  various 
headache  powders.  Lately  he  had  been 
using  from  six  to  twenty  '"orangeine" 
powders  daily.  Attempts  to  withdraw 
the  drug  being  followed  by  intense 
headache,  small  doses  of  morphine  were 
substituted  without  the  patient's  knowl- 
edge. All  the  symptoms  disappeared 
and  the  patient  left  the  hospital  with- 
out having  taken  either  acetanilide  or 
morphine  for  two  or  three  weeks  and 
without  the  knowdedge  that  he  had  had 
•  the  latter.  The  headache  did  not  re- 
turn. J.  C.  Wilson  (Boston  Med.  and 
Surg.  Jour.,  Feb.  22,  1906). 

APPLIED  THERAPEUTICS  OF 
ACETANILIDE.— There  is  no  ordi- 
nary acute  febrile  state  (the  tempera- 
ture remaining  below  105.5°  F.)  in 
which  the  use  of  acetanilide  as  an 
antipyretic  is  warranted.  In  typhoid 
fever,  for  example,  it  causes,  as  shown 
above,  and  even  when  given  in  very 
small  doses,  marked  depression  tend- 
ing to  collapse.  It  favors  in  no  way 
the  curative  process,  and  the  more  or 
less  sudden  fall  produced  deprives  the 
clinician  of  an  important  danger-sig- 
nal which  points  to  intestinal  hemor- 
rhage, and  thus  prevents  the  utiliza- 
tion of  measures  calculated  to  arrest 
it.  The  comfort  acetanilide  brings  to 
the  patient  is  the  treacherous  and 
insidious  dulling  of  all  sensations 
many  poisons  afford;  it  may  be  pro- 
cured quite  as  effectively  and  with 
benefit  to  the  patient  by  means  of 
cold  baths,  cool  sponging,  etc.,  by 
abstracting  heat.  Acetanilide  does 
not  shorten  the  course  of  fevers, 
does  not  prevent  complications  nor  re- 
duce the  mortality.  The  same  reasons 
that  prevail  against  its  use  in  febrile 
processes  cause  acetanilide  .  to  be 
contraindicated  in  phthisis.  It  has 
been  used  to  counteract  the  afternoon 


rise  of  temperature,  but  the  advan- 
tage gained  is  more  than  offset  by 
the  depression  produced.  Ten  grains 
in  divided  doses  have  produced 
collapse. 

Most  authorities,  however,  advocate 
the  use  of  acetanilide  or  other  anti- 
pyretics of  the  coal-tar  series  when 
the  temperature  is  sufifiiciently  high  to 
endanger  life,  i.e.,  in  hyperpyrexia. 

[Acetanilide  is  not  a  true  antipyretic.  By 
causing  constriction  of  the  arterioles  it 
merely  reduces  the  volume  of  blood  admitted 
into  the  tissue-capillaries  and  causes  it  to 
accumulate  in  the  deep  vascular  trunks.  It 
does  not  stay  the  progress  of  the  disease, 
but  tends  to  interfere  with  the  curative 
process  by  preventing  the  free  access  of  the 
antitoxic  and  bactericidal  substances  to  the 
diseased  area. 

Acetanilide  is  not  even  valuable  in  hyper- 
thermia, since  it  does  not  diminish  in  the  least 
the  excessive  production  of  antibodies  to 
which  the  hemolysis  and  autolysis  are  due. 
Thus,  Schiitze  (Zeit.  f.  Hygiene,  Bd.  xxxviii, 
S.  205,  1901)  and  Beniasch  (Zeit.  f.  klin.  Med., 
Bd.  xlv,  S.  51,-1902)  have  both  found  that  the 
proportion  of  protective  antibodies  in  the 
blood  is  not  modified  by  coal-tar  antipyretics, 
the  agglutinating  properties  being  in  no  way 
diminished,  even  when  very  large  doses  were 
given  to  infected  animals.  The  destructive 
process  is  merely  transferred  to  the  deeper 
vessels.  As  previously  stated,  therefore,  ex- 
cessively high  temperature  (above  105.5°  F.) 
or  a  temperature  sufficiently  high  to  produce 
discomfort  is  best  treated  by  means  of 
hydrotherapeutic  methods,  especially  cool 
sponging.     C.  E.  de  M.  S.] 

It  is  in  the  diseases  of  the  nervous 
system  that  acetanilide  has  shown 
itself  most  valuable.  As  an  analgesic, 
especially  in  cases  of  neuralgia  or 
neuritis,  or  in  pain  from  reflex  causes, 
acetanilide  has  been  of  marked  bene- 
fit. In  sciatica,  migraine,  intercostal 
neuralgia,  gastralgia,  the  pain  of  optic 
neuritis  and.  glaucoma,  it  has  been 
freely  used,  and  still  maintains  a  well- 
deserved  reputation.     It  is  also  effect- 


1—15 


226 


ACETANILIDE    (SAJOUS). 


ive    in   the    neuralgic   pains    associated 
with  herpes  zoster. 

[Whichever  of  the  many  causes  of  these 
disorders  prevails,  the  pain  is  always  due,  as 
shovi^n  elsewhere  ("Internal  Secretions," 
vol.  ii,  p.  1529),  to  engorgement  of  the  mi- 
nute vessels,  the  vasa  nervorum,  that  sup- 
ply blood  to  nerves,  and  the  pressure  they 
exert  upon  the  nervi  nervorum,  which,  as 
shown  by  Horsley,  terminate  in  minute  sen- 
sory bulbs.  Acetanilide,  by  causing  constric- 
tion of  the  arterioles  which  supply  these 
neural  vessels,  diminishes  their  hyperemia, 
and  thereby  arrests  the  pain. 

In  some  cases,  especially  when  full  doses 
of  acetanilide  cannot  be  given,  the  neural 
hyperemia  is  further  counteracted  by  giving 
sodium  bromide  (10  or  15  grains)  or  nitro- 
glycerin (YioQ  grain)  or  again  spirit  of 
nitrous  ether  (J^  to  1  dram)  with  each  dose. 
All  three  agents,  by  causing  general  vaso- 
dilation, cause  the  blood  to  accumulate  in  the 
deeper  vessels,  and  thus  to  deplete  those  of 
the  periphery,  including  the  vessels  of  the 
painful  nerves. 

In  sciatica,  acetanilide  is  aided  by  sodium 
salicylate,  which,  besides  causing  constriction 
of  the  arterioles,  also  promotes  the  destruc- 
tion of  toxic  wastes,  the  underlying  cause  of 
the  sciatica.  The  doses  of  both  agents  should 
be  small,  however,  to  avoid  undue  constric- 
tion of  the  cardiac  arterioles,  and  the  result- 
ing depression.     C.  E.  de  M.  S.] 

All  headaches  that  are  severe  or 
long-continued  or  of  regular  recur- 
rence should  be  carefully  studied  and 
the  causative  disorder  treated.  The 
most  satisfactory  temporary  treat- 
ment in  the  author's  experience  has 
been  the  following,  varied  according 
to  age   and   other  conditions: — 

I^  Acetanilidi 3j_ (4.000) . 

Sodii  broniidi  3ij  (8.000). 

CaffeincE  citratce   gr.  iv  (0.250). 

Elix.  guarancB.  .q.  s.ad  §ij  (60.000). 
One  teaspoon  ful  every  three  hours  for 
headache.     E.  M.  Alger   (Therap.  Gaz., 
Dec,  1903). 
The    painful    menstruation,    espe- 
cially in  young  girls,  ovarian  pain  and 
the  circulatory  and  nervous  disturb- 
ances   occurring    at    the    menopause 
often  yield  to  it.     It  has  been  used 
with  benefit  in  chorea. 


[The  manner  in  which  acetanilide  relieves 
pain  in  menstrual  disorders,  etc.,  is  similar 
to  that  in  neuralgia. 

In  chorea,  it  is  the  hyperemia  of  the  cere- 
brospinal and  muscular  systems  which  under- 
lies the  choreic  movements  that  is  reduced 
by  acetanilide.  This  drug  sometimes  proves 
a  valuable  adjuvant,  moreover,  to  remedies 
addressed  to  the  cause  of  the  disorders.     S.] 

In  the  lightning  and  girdle  pains  of 
tabes,  acetanilide  has  been  found  very 
effective  by  Lepine,  Grasset,  Hayem 
and  others.  But  10-grain  (0.66  Gm.) 
doses  are  required.  These  subdue  the 
suffering  in  one-half  hour  and  can  be 
renewed  when  necessary. 

[This  is  produced  in  the  same  way,  the 
pains  being  due  mainly  to  hyperemia  of  the 
central  and  peripheral  nervous  elements,  in- 
cluding the  nervi  nervorum.    C.  E.  de  M.  S.] 

■  In  epilepsy,  acetanilide  has,  on  the 
whole,  not  shown  itself  very  useful, 
except  in  cases  characterized  by  per- 
manently high  vascular  tension.  At 
best,  however,  it  serves  but  to  defer 
the  paroxysms.  This  applies  also  to 
tetanus. 

[The  spasms,  interpreted  from  my  stand- 
point, are  caused  by  toxic  wastes,  which,  by 
exciting  the  vasomotor  center,  produce  an  in- 
tense rise  of  blood-pressure  and  hyperemia 
of  the  cerebrospinal  system.  By  contract- 
ing the  arterioles,  acetanilide  counteracts 
this  hyperemia,  but,  of  course,  only  tempo- 
rarily, and  thus  reduces  the  number  of  con- 
vulsions in  a  given  time.  It  is,  however,  at 
best,  a  palliative.     C.  E.  de  M.  S.] 

Vomiting  of  nervous  origin  or  due 
to  marked  gastric  irritability  occa- 
sionally yields  to  its  action.  Two 
grains  every  hour  until  6  grains  have 
been  taken  usually  suffice  to  arrest 
this  morbid  symptom.  It  gives  some 
relief  in  seasickness  in  doses  of  3  to  5 
grains  (0.20  to  0.32  Gm.). 

In  pertussis,  acetanilide  has  been 
found  to  lessen  the  paroxysms  mark- 
edly.    It  can  be  given  in  doses  of  j4 


ACETANILIDE    (SAJOUS). 


227 


to   Yj   grain    (0.016   to  0.032   Gm.)    in 
small  children. 

[Fcrtussis,  from  my  viewpoint  ("Internal 
Secretions,"  vol.  ii,  p.  1716),  is  clue  to  irri- 
tation of  the  sensory  terminals  of  the  respira- 
tory tract  hy  a  pathogenic  agent  of  un- 
known identity.  Acetanilide,  by  causing  con- 
striction of  tlie  arterioles,  reduces  the  blood 
supplied  to  the  terminals,  and  markedly 
reduces  the  re Hex  cough  they  provoke. 
C.  E.  DE  M.  S.] 

Acetanilide  has  been  used  with  ad- 
vantage in  influenza.  But,  as  antipy- 
rine  and  acetphenetidin  are  quite  as 
effective  and  less  prone  to  produce 
untoward  effect,  they  should  be  given 
the  preference. 

Increased  comfort  to  the  patient 
and  occasionally  general  improve- 
ment have  been  secured  by  the  use  of 
acetanilide  in  diabetes  mellitus. 

[In  this  condition  the  cutaneous  irritation, 
especially  the  pruritus,  is  often  a  source  of 
considerable  suffering.  Acetanilide,  by  caus- 
ing constriction  of  the  cutaneous  arterioles 
and  thus  diminishing  the  hyperemia,  affords 
considerable  relief.  Moreover,  it  tends  di- 
rectly to  counteract  the  morbid  process  itself 
by  inhibiting  in  the  same  way  the  functions 
of  the  adrenals,  which  (see  "Internal  Secre- 
tions," p.  1583)  are  overactive  in  this  dis- 
ease. The  drug  is  A'aluable,  however,  only 
in  sthenic  cases  and  should  be  avoided  when 
the  disease  is  advanced.     C.  E.  de  M.  S.] 

In  ordinary  myalgias,  especially 
lumbago,  acetanilide  proves  some- 
times very  effective.  It  relieves  not 
only  the  pain,  but  also  the  stiffness. 
It  has'likewise  been  recommended  in 
acute  articular  rheumatism,  especially 
when  the  pain  and  swelling  are 
marked.  It  should  not  be  given  when 
cardiac  complications  are  present. 
Doses  of  5  grains  (0.3  Gm.)  not 
oftener  than  three  times  daily  usually 
suffice. 

[From  my  viewpoint  this  form  of  rheu- 
matism is  due  (see  "Internal  Secretions," 
vol.  ii,  p.  1868)  to  capillary  hyperemia.     The 


beneficial  action  of  acetanilide  is  the  result, 
therefore,  of  diminution  of  the  volume  of 
blood  admitted  into  these  vessels.  The  fol- 
lowing combination  has  been  found  efficacious 
in  cases  which  had  resisted  the  action  of 
salicylates  : — 

R;  Aceianilidi   gr.  xxiv  (1.6  Gm.). 

Camphorcc  monobrom.  gr.  xij    (0.8  Gm.). 
M.  et  div.  in  capsulas  no.  xij. 

Sig. :  One  every  three  hours  three  times, 
then  every  four  hours.     C.  E.  de  M.  S.] 

Harnsberger  found  the  drug  useful 
in  threatened  abortion  and  in  habitual 
miscarriages. 

[Abortion  is  often  due  to  congestion  of 
the  uterus.  Hence  the  beneficial  action  of 
acetanilide  in  certain  cases.  By  causing  con- 
traction of  its  arterioles,  it  is  also  useful 
in  all  cases  to  arrest  the  hemorrhage. 
C.  E.  DE  M.  S.] 

The  drug  is  sometimes  used  inter- 
nally in  the  treatment  of  coryza. 
In  pharyngeal  irritation  and  inflam- 
mation it  is  eft'ective  internally, 
especially  when  aided  b}^  a  gargle 
of  4  grains'  (0.25  Gm.)  to  the  ounce 
(30  c.c.)  of  water.  Insufflations  of 
acetanilide  are  very  useful  in  tonsil- 
litis. 

[As  these  are  all  catarrhal  processes  in 
which  hyperemia  is  the  main  morbid  con- 
dition, the  mode  of  action  of  acetanilide  is 
self-evident.    C.  E.  de  M.  S.] 

LOCAL  USES.— Acetanilide  has 
been  employed  with  benefit  in  cutane- 
ous disorders,  such  as  eczema,  psori- 
asis, urticaria,  and  herpes,  usually  in 
.  an  ointment.  It  may .  be  used  in 
powder  form  to  dust  over  the  initial 
lesion  of  syphilis,  mucous  patches, 
and  chronic  ulcerations,  as  well  as 
chancroids.  It  has  been  employed  in 
injections  for  the  treatment  of  ure- 
thritis and  vaginitis.  The  proportion 
of  the  drug  used  in  ointment  or  liquid 
applications  is  generally  from  20  to 
40  grains  to  the  ounce.  It  has  been 
extensively  used  as  an  antiseptic  and 


228 


ACETIC  ACID    (SAJOUS). 


analgesic  in  wounds  and  burns  of 
varying  extent,  one  of  its  main  advan- 
tages being  lack  of  odor.  It  is  best 
used  in  combination  with  an  equal 
part  of  finely  divided  boric  acid. 

The  danger  of  absorption  and 
poisoning  by  the  drug  render  its  local 
use  unwise,  however,  in  any  but 
minor  injuries,  and  the  quantity  ap- 
plied at  each  dressing  should  not 
exceed  that  of  a  moderate  dose  given 
internally.  We  have  submitted  under 
the  heading  "Poisoning  by  Absorption" 
several  illustrative  cases. 

C.  E.  DE  M.  Sajous 

AND 

L,  T.  DE  M.  Sajous, 

Philadelphia. 

ACETIC  ACID.-Acetic  acid 
is  an  organic  acid  obtained  from  sugar 
or  wood  by  distillation,  or  from  ethyl 
alcohol  by  oxidation ;  or  again  from 
crude  pyroligneous  acid.  It  is  also 
formed  normally  in  the  stomach,  from 
sugars  and  alcohol  taken  as  foods. 

PROPERTIES.— Acetic  acid  is  a 
clear,  colorless  fluid  having  a  strong 
pungent  odor  and  an  intensely  acid  cor- 
rosive taste.  It  contains  36  per  cent, 
of  glacial  acetic  acid :  a  monohydrate 
presenting  the  physical  properties  of 
acetic  acid,  which,  in  turn,  becomes 
crystalline  at  34°  F. 

The  dilute  acetic  acid  is  officially  pre- 
pared by  adding  1  part  of  acetic  acid  to 
5  of  water.  Good  vinegar  corresponds 
approximately  in  strength  with  dilute 
acetic  acid.  Each  is  used  as  a  local 
astringent,  and  internally  or  by  inhala- 
tion as  a  stimulant. 

Glacial  acetic  acid  is  employed  as  an 
escharotic.  The  crystalline  form  is 
mainly  employed  with  sulphate  of 
potassium  in  the  preparation  of  smell- 
ing-salts. 


Trichloracetic  acid  prepared  by  treat- 
ing acetic  acid  with  chlorine,  which 
occurs  in  the  form  of  deliquescent 
crystals,  is  to  be  preferred  as  an 
escharotic. 

USES  AND  DOSE.— The  prepara- 
tions available  are : — 

Glacial  Acetic  Acid  (Acidum  Accti- 
cum  Glaciate)  ;  escharotic. 

Acetic  Acid  (Acidum  Aceticum)  ; 
used  externally. 

Dilute  Acetic  Acid  (Acidum  Aceti- 
cum Dilutum,  6  per  cent.)  ;  dose,  ^  to 
1  dram  (2  to  4  c.c). 

Trichloracetic  Acid  (Acidum  Tri- 
chloraccticum) ;   escharotic. 

It  is  miscible  with  alcohol  or  water 
in  all  proportions. 

PHYSIOLOGICAL  ACTION.— 
Applied  to  the  skin  glacial  acetic  acid 
caused  irritation  and  pain,  and  the  for- 
mation of  a  vesicle ;  its  local  applica- 
tion to  mucous  membranes  is  attended 
by  immediate  blanching  of  the  cellular 
elements  cauterized.  When  applied  to 
the  skin  well  diluted,  as  vinegar,  for 
example,  it  acts  as  an  astringent  and 
produces  cold  and  pallor  of  the  tissues 
it  touches.  Greatly  diluted,  as  a  bever- 
age, it  quenches  thirst.  In  the  blood  it 
combines  with  the  alkaline  bases,  is 
transformed  into  acetates,  and  then  into 
sodium  bicarbonate,  and  thus  acts  as  a 
diuretic  and  diaphoretic. 

ACETIC  ACID  POISONING.— 
The  abuse  of  vinegar,  or  vegetables  and 
other  foods  preserved  in  this  agent, 
tends  to  produce  anorexia,  gastric  dis- 
orders, diarrhea  and  emaciation.  In 
toxic  doses  acetic  acid  causes  intense 
irritation,  owing  to  its  property  of  ef- 
fecting a  partial  solution  of  albuminous 
bodies  and  of  dissolving  gelatinous  tis- 
sues. This  escharotic  action,  by  mani- 
festing itself  upon  the  mucous  mem- 
brane  of  the  pharynx  and  larynx,  is 


ACETIC  ACID    (SAJOUS). 


229 


liable  to  cause  edema  of  the  glottis :  a 
danger  to  be  at  once  thought  of.  The 
immediate  manifestations  are  severe 
pain  in  the  mouth,  throat,  esophagus, 
and  stomach,  with  retching  and  vomit- 
ing and  other  symptoms  attending 
violent  irritation  of  the  digestive  tract. 
General  symptoms  then  manifest  them- 
selves :  The  heart's  action  becomes 
rapid  and  the  pulse  extremely  weak  or 
imperceptible,  the  face  and  extremities 
being  cold  and  clammy  and  covered 
with  sweat.  In  very  acute  cases, 
somnolence  passes  into  coma,  and  death 
ensues. 

In  moderately  severe  cases,  there 
occurs,  after  the  disappearance  of  the 
acute  symptoms,  abundant  expectora- 
tion of  mucus,  containing  necrosed  tis- 
sue, and  slight  fever,  due  to  more  or 
less  pyemia.  The  blood  is  markedly 
influenced,  as  shown  by  the  marked 
anemia,  paleness  and  distortion  of  the 
red  corpuscles  and  other  phenomena. 
Such  a  case  usually  recovers. 

[What  experimental  evidence  is  available 
is  too  scanty  to  warrant  a  conclusion  as  to 
the  manner  in  which  it  produces  physiolog- 
ical effects.  It  would  seem,  however,  as  if 
the  general  phenomena  awakened  by  a  toxic 
dose  of  acetic  acid  were  reflex  in  character, 
the  vagus  transmitting  the  afferent  or  sen- 
sory impulses  from  the  cauterized  alimen- 
tary canal,  while  the  sympathetic  carries  the 
efferent  or  motor  impulses  to  the  vessels  it 
supplies,  the  arterioles.  The  cardiac  arteri- 
oles being  constricted  and  the  myocardium 
thus  inadequately  supplied  with  blood,  the 
heart's  action  becomes  weak  and  the  pulse- 
wave  likewise.  A  similar  condition  prevail- 
ing throughout  the  entire  organism  the  body 
is  cold  and  clammy,  and  relaxation  of  the 
spiral  muscles  of  the  sweat-glands  causes 
passive  sweating.  A  corresponding  interfer- 
ence with  the  circulation  of  the  brain  causes 
somnolence  and  finally  coma. 

These  general  phenomena  last  during  the 
inflammatory  phase  of  the  lesions  in  the 
alimentary  canal,  the  seat  of  reflex  excita- 
tion.    C.  E.  DE  M.  S.] 


Treatment  of  Acetic  Acid  Poison- 
ing.— yMkalies  and  demulcents  should 
be  employed.  The  bicarbonate  of  soda 
in  free  soltition  is  an  effective  remedy. 
Ordinary  soap — one  containing  an  al- 
kali— can  be  used  in  solution  until 
an  alkaline  salt  is  available.  Chalk, 
lime  or  even  wood  ashes  may  be  em- 
ployed in  the  absence  of  an  alkaline 
soap.  Milk,  white  of  egg,  oil  or  flax- 
seed tea  are  useful  to  form  a  coating 
over  the  esophagus  and  stomach. 

Case  of  a  girl,  aged  19  years,  who 
swallowed  a  considerable  amount  of 
strong  acetic  acid  with  suicidal  intent. 
She  immediately  was  seized  with  violent 
vomiting  and  with  pain  and  intense 
burning  in  the  mouth  and  pharynx.  At 
the  hospital  she  developed  a  series  of 
pronounced  symptoms,  which  are  inter- 
esting in  view  of  the  rarity  of  cases  of 
acetic  acid  poisoning.  There  was  a  fre- 
quent and  feeble  pulse  and  a  slightly 
elevated  temperature,  a  persistent  and 
violent  cough  with  a  very  abundant 
purulent  expectoration,  a  veritable  bron- 
chorrhea,'  and  occasionally  efforts  at 
vomiting  which  were  not  successful. 
The  urine  was  black  and  smoky,  like 
that  of  carbolic  acid  poisoning,  and 
contained  1  per  cent,  of  albumin.  The 
red  blood-disks  in  the  fresh  blood 
were  very  pale,  with  little  tendency  to 
form  rouleaux,  and  with  frequent  mul- 
berry-shaped distortion.  The  serum, 
when  separated,  had  a  distinct  reddish 
tint,  showing  that  the  hemoglobin 
had  been  dissolved  from  the  cells. 
The  heart-sounds  and  the  apex-beat 
were  very  weak.  The  symptoms 
gradually  disappeared,  and  the  pa- 
tient was  discharged  cured.  The 
treatment  consisted  of  stimulation  in 
the  shape  of  injections  of  caflfeine,  a 
milk  diet,  and  the  use  of  pieces  of  ice 
and  of  a  tannin  gargle  for  the  throat. 
Special  attention  called  to  the  changes 
in  the  blood,  the  purulent  bronchitis, 
and  the  degenerative  changes  in  the 
myocardium  resulting  in  heart-weak- 
ness with  danger  of  cardiac  failure. 
Giordano  (Riforma  Medica,  Jan.  27, 
1904). 


230  ACETIC  ACID    (SAJOUS). 

To  counteract  the  general  symptoms,  Between  times  a  stimulating  oil — as 

strychnine  or  caffeine  may  be  used,  of  eucalyptus  and  turpentine,  of   each 

To  relieve   the   burning   sensation   in  y2  ounce ;  crude  petroleum  and  alcohol, 

the    alimentary    canal,    morphine    is  of  each   1   ounce — is  applied.     This  is 

sometimes  used.  to  be  followed  by  a  thorough  massage 

THERAPEUTICS.— As    an    anti-  of  the  scalp   for  five  minutes  by   the 

septic,  acetic  acid  is  possessed  of  con-  patient.     Once  a  week,  or  oftener,  the 

siderable  power.    As  such  it  may  either  scalp   is   to   be   thoroughly    shampooed 

be  applied  locally  or  its  fumes  may  be  with  tincture  of  green  soap  (Morrow). 

inhaled.  I^i  rodent  ulcer  and  lupus  vulgaris 

In  an  emergency  vinegar  is  useful  for  acetic  acid  is  of  use.     Daily  applications 

disinfecting  the   hands   and   the    region  of    a    75   per   cent,    solution    and    subse- 

operated  upon.    L.  Fiirst  (Deut.  Aerzte-  quent  rinsing  with  w^ater  are  necessary. 

Zeit.,  June  lo,  1900).  jj^  sunburn  and  the  various  forms  of 

Acetic  acid  is   frequently  used  as   a  dermatitis  dilute  acetic  acid  or  vinegar 

stimulant.     When  inhaled  its  stimulat-  ^^"^its  greatly  the  cutaneous  hyperemia, 

ing  effects  upon  the  nervous  supply  of  ^he  main  source  of  discomfort, 

the  nasal  mucous  membrane  causes  it  ^^^^^^  coryza  is  sometimes  arrested 

to   sometimes   act   rapidly   in   restoring  ^y  *e  inhalation  of  acetic  acid.     This 

consciousness    after    fainting.     In    the  ^PP^ie^  also  to  epistaxis;  in  persistent 

same  manner  it  may  also  arrest  vomit-  ^ases,  a  tablespoonful  of  vmegar  m  a 

ing  and  headaches  of  nervous  origin.  glassful  of  water  hastens  materially  the 

Acetic  acid  is  useful  in  many  dis-  beneficial  effect  inhalations  afford, 
orders  of  the  skin.  As  an  escharotic  it  Glacial  acetic  acid  is  useful  in  pre- 
is  often  used  on  corns,  warts,  condylo-  renting  the  development  of  hay  fever 
mata,  and  fungous  grov^ths.  The  gla-  ^y  applications  after  local  anesthesia 
cial  acetic  acid  should  be  used  for  this  ^^^^h  a  10  per  cent,  solution  of  cocaine 
purpose.  For  the  destruction  of  papil-  ^^  sensitive  areas  of  the  nasal  mucous 
lomata  and  other  small  growths,  the  membrane  twice  per  week.  In  prac- 
trichloracetic  acid  is  more  effective,  t'^^l^^  ^^^  ^^^es,  however,  the  applica- 
The  neoplasm  is  first  anesthetized  with  tions  must  be  renewed  each  year.  In 
cocaine,  and  a  single  crystal  of  the  acid  hypertrophic  rhinitis  it  may  also  be 
is  placed  upon  it.  This  produces  a  "^ed  m  the  same  way;  but  chromic 
white,  dry  mass  which  falls  off.  In  ^^^^  is  more  effective.  In  pharyngitis 
alopecia  it  has  been  used  with  advan-  ^^d  tonsillitis  gargling  with  equal  parts 
tage  as  a  vesicant.  When  it  is  extensive  ^f  vinegar  or  dilute  acetic  acid  and 
the  scalp  should  be  shaved  and  dilute  ^^^er  sometimes  proves  very  efficient, 
acetic  acid  with  equal  parts  of  chloro-  ^^  tuberculous  laryngitis  it  has 
form  and  ether  applied.  Or  Besnier's  g^^^n  good  results  m  arresting  ulcer- 
formula  may  be  employed:-  ^^ion.    The    ulcers    are    first    scraped 

and  the  acid  applied  with  a  laryngeal 

^  Chlorali  hydrati 75  grs.  applicator.     Inhalations  of  a  2-  to  3- 

^theris 6  drs.  ^          i    -•         .i            -•                 j 

,  . ,.         .  .                      ,^  ^^  per  cent,  solution  three  times  a  day, 

Acidi  acehci  cryst 15-75  grs.  ^            .                              .                               / 

„               ,.      .                         ,   ,  ten   minutes    at   a   time,    and    contm- 
Misce.      These    apphcations    are    repeated 

two  or  three  times  a  week  at  first,  and  later  "ed  several  weeks,  have  been  recom- 

at  longer  intervals.  Hiended  by  several  German  observers. 


ACETONURIA    (LEVISON  AND  ERLANDSEN). 


231 


Acetic  acid  has  also  been  found  an 
excellent  adjuvant  in  the  treatment  of 
pulmonary  tuberculosis  and  bronchitis 
Avhen  used  e\er}-  three  hours.  A  con- 
venient method  is  to  pour  about  a 
teaspoonful  on  a  saucer  and  to  place 
this  over  a  tire.  The  acid  is  then 
inhaled  Avhile  it  is  evaporating — about 
ten  minutes.  At  first  it  proves  irri- 
tating, but  this  soon  subsides.  It  is 
useful  in  night-sweats  applied  as  a 
lotion.  Vinegar  half  diluted  with 
water  is  quite  as  effective. 

Diluted  with  from  one  to  four  parts 
of  water,  dilute  acetic  acid  is  recom- 
mended by  Wood  in  hematemesis.  It 
has  been  recommended  by  Hayem  for 
dyspepsia,  especially  where  the  digest- 
ive activity  is  deficient,  i.e.,  in  hypo- 
pepsia. 

It  is  a  good  succedaneum  for  hydro- 
chloric acid  in  the  treatment  of  gastric 
and  acute  or  chronic  intestinal  ca- 
tarrh, ordinary  vinegar,  a  tablespoonf  ul 
to  half  a  pint  of  water,  being  taken 
daily.  It  is  indicated  in  those  submitted 
to  a  diet  rich  in  carbohydrates  and  un- 
able to  take  much  exercise.  It  also 
controls  summer  diarrhea  and  true 
cholera  nostras,  vinegar  rapidly  and 
certainly  killing  the  bacillus  of  cholera. 

Inhalations  of  acetic  acid  are  very 
effective  in  the  vomiting  of  chloroform 
narcosis,  administered  as  in  the  "drop" 
method  of  anesthesia,  the  napkin  be- 
ing held  near  the  nose,  but  not  in  con- 
tact with  the  tissues. 

Dilute  acetic  acid  or  vinegar  is  efifi- 
cient  as  a  topical  application  for  sprains 
and  bruises  and  reduces  greatly  the  ef- 
fusion and  pain. 

C.  E.  DE  M.  Sajous 

AND 

L.  T.  DE  M.  Sajous, 

Philadelphia. 


ACETONE   BROMOFORM, 

See  I5R0MINE. 

ACETONE  CHLOROFORM. 

See   ClILORETONE. 

ACETONURIA.  — Acetone 
(C3rioO=  dimethylketone  =  CH3— 
CO — CH3)  is  a  thin,  watery,  vei-y 
mobile,  colorless  liquid  of  neutral  re- 
action. It  has  a  curious  aromatic 
odor,  resembling  somewhat  that  of 
acetic  ether  or  of  oil  of  peppermint. 
It  is  soluble  in  water,  in  alcohol  and 
ether  in  all  proportions ;  evaporates  at 
ordinary  temperatures;  boils  at  56.3° 
C,  and  has  a  specific  gravity  of  0.81. 
Acetone  can  be  obtained  by  the  dis- 
tillation of  acetate  of  barium.  Oxida- 
tion of  acetone  causes  the  formation 
of  acetic  acid  and  formic  acid.  As  a 
product  of  metabolism,  it  was  dis- 
covered by  Fetters,  in  1857,  in  the 
urine  of  a  diabetic  patient. 

Acetone  is  found  in  the  urine  of 
healthy  individuals  in  quantities  not 
exceeding  10  mg.  per  day,  which,  dur- 
ing starvation  (Mfiller),  can  increase 
to  780  mg.  per  day.  In  some  diseases 
it  increases  to  0.2  to  0.5  gram  daily. 
By  distilling  the  urine  examined,  ace- 
tone can  be  obtained  in  a  purer  state, 
although  still  united  with  other  volatile 
constituents  of  the  urine. 

PHYSIOLOGICAL  AND  PATH- 
OLOGICAL EXCRETION  OP 
ACETONE.  —  Pathological  acetonu- 
ria  is  observed  (1)  in  high  febrile 
states ;  (2)  in  diabetes,  especially  in 
advanced  cases;  (3)  in  some  forms  of 
carcinoma  which  have  not  as  yet  in- 
duced inanition ;  (4)  in  psychoses ; 
(5)  in  autointoxication;  (6)  in  func- 
tional insufficiency  of  the  pancreas ; 
(7)  during  the  excessive  use  of  animal 
foods,  and  (8)  in  different  disorders 
of   the    digestion.      Lorenz    observed 


232 


ACETONURIA    (LEVISON  AND  ERLANDSEN). 


acetonuria  and  excretion  of  acetone 
with  the  feces  and  the  vomited  matter 
in  a  case  of  peritonitis.  In  fever  ace- 
tonuria is  constantly  observed,  and  in 
the  fevers  of  children  as  well  (Ba- 
ginsky).  In  cases  of  diabetes, acetonu- 
ria occurs  when  the  disease  has  con- 
tinued for  a  long  time,  and  especially 
when  the  patients  are  put  on  an  ex- 
clusive diet  of  proteids  or  proteids  and 
fat,  or  when  the  allowance  of  food  is 
not  sufficient  to  maintain  the  equilib- 
rium of  metabolism. 

In  fevers,  as  well  as  in  diabetes, 
acetonuria  is  often  accompanied  by 
excretion  of  diacetic  acid  and  beta- 
oxybutyric  acid. 

Five  cases  of  gastric  disturbances  ac- 
companied by  elimination  of  acetone 
and  acetic  acid;  the  breatli  had  the 
pecuHar  odor  of  acetone  at  times.  Only 
a  few  of  the  children  had  fever  during 
these  attacks.  The  children  were  be- 
tween 3  and  11  years  old.  The  writer 
ascribes  the  vomiting  to  efforts  at 
elimination.  Hecker  (Miinch.  med. 
Woch.,  July  14,  1908). 

The  presence  of  acetonuria  seems  to 
possess  some  diagnostic  value  in  dif- 
ferentiating between  diphtheria  and 
scarlet  fever,  on  the  one  hand,  and  an 
ordinary  sore  throat,  on  the  other.  It 
is  much  more  constantly  present  in  the 
former  cases.  In  adults,  even  in  diph- 
theria and  scarlet  fever,  it  is  not  pres- 
ent so  constantly  as  in  children. 

Of  197  consecutive  cases  of  scarlet 
fever  admitted  into  the  Isolation  Hos- 
pital, Southampton,  167  were  found  to 
have  acetonuria,  which  is  equal  to  a 
percentage  of  84.8.  Of  96  cases  of 
diphtheria  87  were  found  to  have  ace- 
tonuria, which  is  equal  to  a  percentage 
of  90.6.  Of  the  adults  admitted  8  had 
acetonuria  and  7  had  none.  There  were 
only  2  cases  of  diphtheria  in  chil- 
dren in  which  no  acetone  was  found; 
1  of  these  cases  was  one  of  laryngeal 
diphtheria  in  which  the  toxic  symptoms 
of  diphtheria  are  generally  absent.  Of 
21  cases  of  enteric  fever  only  7  showed 


some  evidence  of  acetonuria,  which  is 
equal  to  a  percentage  of  33.3.  In  6 
of  these  7  cases  the  acetonuria  was  so 
slight  as  to  be  only  with  difficulty  dem- 
onstrated. Of  the  14  cases  that  had  no 
acetone  in  the  urine  8  were  severe 
cases.  Alfred  Harris  (Lancet,  May 
14,  1910). 

Case  of  periodical  vomiting  and  ace- 
tonuria in  a  child.  The  patient  was 
a  boy  of  about  3,  much  depressed  by 
the  periodical  vomiting.  The  odor  of 
acetone  permeated  the  air  of  the  room. 
He  had  seven  attacks  of  the  recurring 
vomiting,  each  accompanied  by  much 
acetonuria,  during  the  two  years  after- 
ward, but  then  he  seemed  to  outgrow 
the  tendency  and  is  now  an  apparently 
healthy  child.  Adenoid  vegetations 
had  been  removed  in  the  interim. 
Bloch  (Hospitalstidende,  June  8,  1910). 

It  occurs  also  in  association  with 
typhus,  pneumonia,  variola,  scarlet 
fever,  perityphlitis,  Bright's  disease 
and  strangulated  hernia,  but  it  does 
not  lead  in  such  cases  to  diabetic 
coma. 

Case  of  autointoxication  with  ace- 
tonuria and  bradycardia.  The  pulse 
registered  from.  4  to  8  to  the  minute 
and  was  synchronous  with  the  heart 
beat.  This  shows  the  extreme  grade 
of  the  intoxication  of  the  inhibitory 
vital  centers  and  of  the  myocardial  de- 
generation. There  was  a  leucocytosis 
of  22,000.  Two  separate  and  distinct 
toxemias  were  present :  a  clear  history 
of  chronic  nicotine  poisoning  and  an 
acute  infection.  Singer  (N.  Y.  Med. 
Jour.,  June  26,  1909). 

Costa  found  during  the  last  month 
of  physiological  pregnancy  and  in  the 
puerperium  (after  the  eighth  day)  a 
more  marked  acetonuria  than  in  the 
non-pregnant  state.  In  labor  the 
acetonuria  increases.  Acetonuria  can- 
not be  regarded  as  a  sign  of  fetal 
death. 

Twenty-six  cases  of  acetonuria  stud- 
ied. In  physiological  pregnancy  at  the 
ninth  month  the  acetonuria  is  more 
marked  than  in  the  non-pregnant  state. 


ACETONURIA    (LEVISON  AND  ERLANDSEN). 


233 


Til  labor  the  acetonuria  increases,  espe- 
cially if  the  parturition  be  prolonged. 
In  the  puerperium  it  diminishes,  re- 
maining, however,  greater  than  in  preg- 
nancy till  after  the  sixth  day.  The 
view  that  acetonuria  can  be  regarded 
as  a  sign  of  fetal  death  is  not  sustained. 
R.  Costa  (Ann.  di  Ostet.  e  Gynec,  xxiii, 
March,  1901). 

ORIGIN  AND  PATHOLOGICAL 
SIGNIFICANCE  OF  ACETONE, 
DIACETIC  ACID,  AND  BETA- 
OXYBUTYRIC  ACID.— The  origin 
of  acetone  in  the  organism  has  not 
3'et  been  ascertained.  Cantani  was  of 
the  opinion  that  it  was  formed  in  func- 
tional disorders  of  the  digestive  tract; 
Fetters  and  KauHch  argued  that  it 
was  due  to  fermentations  in  the 
bowels.  Markownikoff  ascribed  it  to 
a  fermentative  product  of  sugar. 

Albertoni  did  not  find  acetone  in  the 
urine  of  animals  which  had  received 
large  doses  of  glucose  (100  grams)  or 
of  different  primary  saturated  alcohol ; 
when  isopropylalcohol  was  ingested  it 
was  excretecj  partly  unaltered  and 
partly  changed  to  acetone,  and  when 
acetone  was  given  to  animals  it  was  dis- 
charged by  the  urine,  even  if  the  dose 
of  acetone  ingested  did  not  exceed  8  eg. 

When  Gerhard  detected  the  presence 
in  the  urine  of  a  substance  which  gave 
a  dark  wine-red  color  by  means  of  a 
solution  of  perchloride  of  iron,  he  be- 
lieved this  substance  to  be  diacetic  ether, 
and  was  of  the  opinion  that  acetone  was 
derived  from  this  substance,  which  can 
easily  be  disintegrated  into  acetone, 
alcohol,  and  carbonic  acid. 

Fleischer  and  Tollens  then  demon- 
strated that  Gerhard's  view  was  erro- 
neous, and  found  that  the  coloring 
substance — ^at  least  in  the  majority  of 
cases — must  be  diacetic  acid,  which 
can  be  separated  from  the  urine  by 
the    addition    of    sulphuric    acid    and 


extracted  with  ether.  This  opinion  is 
supported  by  von  Jaksch.  Minkowski 
caused  acetonuria  by  extirpation  of 
the  pancreas,  and  von  Mering  by  in- 
toxication with  phloridzin. 

Lustig  found  that  extirpation  of  the 
solar  plexus  in  animals  provoked  ace- 
tonuria, glycosuria,  and  emaciation, 
while  Oddi  obtained  the  same  results 
by  sugar  injections. 

Lorenz  is  of  the  opinion  that  diacetic 
acid  and  the  beta-oxybutyric  acid  are 
the  substances  from  which  acetone  is 
derived,  and  that  they  are  the  real 
causes  of  the  toxic  symptoms  observed 
in  acetonuria,  while  acetone  itself  is 
relatively  innocuous. 

The  necessary  condition  for  the  pro- 
duction of  acetonuria  is  an  insufficient 
decomposition  of  hydrocarbons,  either 
from  their  absence  in  the  diet  or  from 
impaired  powers  of  decomposition  on 
the  part  of  the  organism  (diabetes). 
In  advanced  diabetes  acetonuria  is  a 
grave  symptom,  threatening  coma.  This 
coma  may  be  delayed  by  the  administra- 
tion of  large  doses  of  sodium  bicarbo- 
nate. It  is  probable  that  the  bodies  of 
the  acetone  series  are  formed  in  con- 
siderable quantity  in  the  organism,  to 
disappear  completely  later.  They  doubt- 
less represent  links  in  a  continuous 
series  of  transformations  in  which  oxy- 
butyric  acid-beta  is  the  primordial  term. 
H.  C.  Geelmuyden  (Norsk  Mag.  f. 
Laegevidensk.,  July,  1900). 

Brewer,  Brackett,  Stone  and  Low 
have  held  that  acetonuria  is  fairly  rare 
and  that  it  is  of  unfavorable  signif- 
icance. The  writer  cannot  agree  with 
these  views.  His  own  conclusions  are : 
1.  Acetonuria  is  of  more  frequent  oc- 
currence than  is  thought.  2.  Its  pres- 
ence without  symptoms  has  no  effect 
on  operative  treatment  or  prognosis. 
3.  Its  presence  with  moderate  symptoms 
is  of  only  slight  importance.  4.  Its 
presence  with  severe  symptoms,  how- 
ever, is  of  the  gravest  prognostic  value. 
Hubbard  (Boston  Med.  and  Surg. 
Jour.,  June  29,  1905). 


234 


ACETONURIA    (LEVISON  AND  ERLANDSEN). 


According  to  Geelmuyden,  the  neces- 
sary condition  for  the  production  of 
acetonuria  is  an  insufficient  decomposi- 
tion of  carbohydrates;  he  thinks  it 
probable  that  the  bodies  of  the  acetone 
series  are  formed  in  considerable  quan- 
tity in  the  organism,  to  disappear  later, 

Hubbard  found  acetonuria  more  fre- 
quent than  is  generally  believed.  Its 
presence  without  symptoms  should 
not  influence  operative  treatment  or 
prognosis.  While  its  presence  with 
moderate  symptoms  is  of  but  slight 
importance,  its  presence  with  severe 
symptoms  renders  the  prognosis  very 
grave. 

Von  Engel  found  a  great  quantity  of 
acetone  in  the  urine  of  a  patient  suffer- 
ing from  lactosuria ;  when  the  milk  was 
removed  by  a  sucking  apparatus  the 
acetonuria  disappeared.  Very  much 
acetone  was  found  in  the  urine  of 
patients  suffering  from  severe  chronic 
morphinism.  In  different  acute  fevers 
acetonuria  is  rather  a  constant  symp- 
tom ;  in  typhoid  fever  von  Engel  found 
it  constantly;  acetone  was  only  missed 
when  the  typhoid  fever  was  accom- 
panied by  obstipation. 

Becker  found  that  acetonuria  in- 
creased after  narcosis,  the  case  being 
the  same  with  an  already  existing 
acetonuria.  This  would  seem  to 
explain  why  acetonuria  has  been  ob- 
served after  great  operations. 

Etherization  itself  will  produce  ace- 
tonuria in  a  certain  number  of  cases, 
but  it  also  seems  very  probable  that 
there  are  a  good  many  other  contrib- 
uting factors  which  must  be  taken  into 
consideration,  such,  for  example,  as 
prolonged  starvation  before  and  after 
operation.  In  a  large  series  of  obser- 
vations made  in  a  children's  hospital  it 
was  found  that  boys  were  more  subject 
to  postanesthetic  acetonuria  than  girls. 
The  length  of  the  anesthesia,  the 
amount  administered,  and  the  duration 


of  the  operation  seem  to  play  no  part 
in  the  duration  and  severity  of  the 
symptoms,  but  the  method  of  adminis- 
tration of  the  ether  seems  to  be  of  con- 
siderable importance,  as  a  comparison 
of  figures  will  show.  In  120  cases 
etherized  by  the  "cone  method,"  ace- 
tone was  found  in  88.5  per  cent.,  while, 
in  the  same  number  of  cases  in  which 
the  drop  method  was  used,  only  26  per 
cent,  showed  acetonuria.  It  would, 
therefore,  seem  perfectly  logical  to 
consider  the  "drop  method"  the  best. 
Hamblen  (Univ.  of  Penna.  Med.  Bull., 
June,  1909). 

Beesly,  Longo;  Young  and  Will- 
iams found  postoperative  acetonuria 
a  quite  common  occurrence  (70  per 
cent.).  The  condition  is  transient, 
lasting  only  from  two  to  eight  days 
(Young  and  Williams).  Acetonuria 
has  no  influence  upon  the  course  of 
the  recovery.  Beesly  holds  that  ace- 
tonuria due  to  chloroform  anesthesia 
is  more  harmful  than  that  caused  by 
ether  anesthesia,  because  ether  is  less 
injurious  to  the  hepatic  and  renal  cells 
and  thus  does  not  inhibit  their  power 
to  carry  on  their  eliminative  functions. 
The  usual  risks  of  anesthesia  are 
not  increased  by  pre-existent  chronic 
acetonuria,  but  anesthesia  (especially 
by  chloroform)  may  be  dangerous 
with  pre-existent  acute  acetonuria. 

In  postanesthesic  acetonuria  two  sep- 
arate conditions  should  be  recognized 
— acute  and  chronic  acetonuria.  Ether 
and  chloroform  invariably  induce  a 
temporary  acute  acetonuria  which  may 
be  very  detrimental,  even  to  an  appar- 
ently healthy  organism.  This  acute 
anesthetic  acetonuria  is  accompanied  by 
symptoms  of  acid  intoxication,  some- 
times ending  in  death,  when  the  kid- 
neys are  unable  to  cope  with  tlie  in- 
creased formation  of  aceto_ne  by  a 
corresponding  incapability  of  excretion. 
Although  ether  may  produce  a  greater 
acetonuria,  this  is  less  harmful  than 
that  produced  by  chloroform,  because 
ether  is  less  injurious  to  the   cells  of 


ACETONURIA    (LEVISON  AND  ERLANDSEN). 


235 


the  liver  and  kidneys,  and  thus  docs 
not  hinder  their  power  of  eUmination. 
The  more  plentifully  and  rapidly  ex- 
cretion is  carried  on,  the  less  serious  is 
the  poisoning.  The  eflfects  of  the  poi- 
soning are  mitigated  by  the  adminis- 
tration of  alkalies,  which  may  also  be 
given  with  advantage  before  operation 
if  poisoning  be   anticipated. 

The  usual  risks  of  anesthesia  are  not 
increased  by  pre-existent  chronic  ace- 
tonuria.  Anesthesia  is  dangerous  with 
■  pre-existent  acute  acetonuria,  especially 
if  the  anesthetic  is  chloroform.  A 
guarded  prognosis  must  always  be 
given  when  acute  acetonuria  is  present 
with  symptoms  of  poisoning.  Death 
following  the  administration  of  chloro- 
form with  symptoms  of  poisoning  may 
be  due  to  the  idiosyncrasy  of  the  pa- 
tient. Lewis  Beesly  (British  Medical 
Journal,  May  19,  1906). 

Study  of  102  cases  with  reference  to 
the  presence  of  acetone  in  the  urine 
after  operations.  The  writer  found  ace- 
tone absent  in  76;  present  in  11  cases 
before  the  operations,  and  absent  in  15 ; 
present  in  86  cases  after  the  inter- 
ventions. Postoperative  acetonuria  is 
therefore  a  quite  common  occurrence. 
The  condition  is  transient,  and  is  caused 
by  both  the  anesthesia  and  the  trau- 
matism. Youth  and  fasting  are  pre- 
disposing factors.  The  acetonuria  has 
no  influence  upon  the  course  of  the 
postoperative  recovery.  Longo  (Ri- 
forma  Medica,  Sept.  15,  1907). 

The  writers  have  made  some  observa- 
tions in  52  cases,  of  whom  only  2,  or 
about  3.8  per  cent.,  had  acetonuria  be- 
fore operation,  while  following  laparot- 
omy acetone  was  found  in  the  urine  of 
27,  or  about  52  per  cent.  The  reaction 
lasted  in  different  cases  from  two  to 
eight  days.  Of  the  2  patients  whose 
urine  contained  acetone  before  opera- 
tion, 1  was  a  colored  girl,  15  years  of 
age,  who  was  operated  upon  for  adhe- 
sions following  an  acute  attack  of 
pelvic  inflammation.  The  operation 
was  short  and  the  convalescence  excel- 
lent. Young  and  Williams  (Boston 
Med.  and  Surg.  Jour.,  Jan.  23,  1908) . 
Acetone,  diacetic  acid,  and  beta- 
oxybutyric   acid   are   found   in    great 


((uantities  in  the  urine  of  diabetic 
coma,  and  different  authors — Munser 
and  vStrassez,  for  in.stance — l)elieve 
the.se  substances  to  be  the  real  cause 
of  coma,  perhaps  by  causing-  an  excess 
of  acidity  in  the  organism. 

In  comatose  patients  who  do  not 
suffer  from  diabetes — as,  for  instance, 
in  saturnine  encephalopathies,  etc. — 
diacetic  acid  is  often  found  in  the 
urine.  Von  Jaksch  has  proposed  to 
give  the  name  of  "coma  diaceticum" 
to  these  cases  of  coma.  Nevertheless, 
neither  acetone  nor  diacetic  acid  and 
oxybutyric  acid  have  very  prominent 
poisonous  properties.  Kussmaul  gave 
animals  6  grams  of  acetone  per  day 
without  effect.  Buhl,  Tappeiner,  and 
Frerichs  came  to  similar  results. 
Albertoni  found  the  lethal  dose  of 
acetone  for  dogs  to  be  about  6  to  8 
grams  per  kilogram  of  the  dog's 
weight. 

Geelmuyden  draws  the  conclusion 
from  many  experiments  on  rabbits 
that,  even  when  small  (10  to  20  mg.) 
subcutaneous  injections  of  acetone  are 
given,  the  acetone  is  excreted  with  the 
urine ;  in  larger  doses  more  acetone  is 
excreted ;  but  only  a  portion  of  the  in- 
jected quantity  reappears;  another 
portion  of  it  is  excreted  with  the  ex- 
pired air;  but  still  a  portion  is  left 
which  does  not  reappear  and  must 
therefore  have  been  disintegrated  in 
the  body  of  the  animal.  After  the  in- 
jections albuminuria  takes  place.  An 
adult  rabbit  can  bear  an  injection  of  2 
grams  of  acetone,  but  is  killed  by  the 
injection  of  6  grams.  In  starving 
animals  the  experiments  gave  the 
same  results;  a  portion  of  the  injected 
acetone  reappeared  in  the  urine  and 
the  expired  air,  while  still  another 
portion  was  disintegrated  in  the  body. 
Geelmuyden  draws  from  these  experi- 


236 


ACETONURIA    (LEVISON  AND  ERLANDSfiM). 


ments  the  conclusion  that  the  aceto- 
nuria  observed  in  starving  individuals 
is  not  caused  by  a  diminution  of  the 
power  to  disintegrate  acetone  already 
.formed  in  the  body,  but  to  an  increase 
of  the  amount  of  acetone  formed  in 
the  body. 

Modern  authors  generally  admit 
that  acetone  is  a  product  of  the  me- 
tabolism of  proteids.  Honigmann  and 
von  Noorden  are  of  the  opinion  that 
acetone  is  only  formed  by  diminution 
of  the  organized  albumin  of  the  body, 
and  never  by  the  metabolism  of  the 
proteids  ingested  with  the  food,  be 
the  quantity  ever  so  large.  Honig- 
mann supported  this  theory  princi- 
pally by  experiments  made  on  him- 
self, which  proved  that  when  he  lived 
exclusively  on  large  quantities  of  pro- 
teids— that  is,  when  nutrition  was  in- 
sufficient— acetone  and  diacetic  acid 
were  found.  The  acetonuria  was  not 
augmented  when  more  albumin  was 
ingested,  but  disappeared  when  he 
took  plenty  of  carbohydrates  in  addi- 
tion to  the  proteids.  Von  Engel,  on 
the  contrary,  is  of  the  opinion  that  in 
all  cases  when  great  quantities  of 
albumin  are  decomposed  in  the  body 
the  quantity  of  acetone  excreted  with 
the  urine  will  increase  considerably, — 
equally  if  the  albumin  is  ingested  with 
the  food  or  taken  from  the  stock  of  the 
body. 

Weintraub  and  Hirschfeld  are  de- 
cided opponents  of  this  theory.  Wein- 
traub argues  that — in  a  case  of  severe 
diabetes  where  complete  equilibrium 
of  the  metabolism,  and  especially  of 
the  metabolism  of  nitrogen,  was  main- 
tained for  a  long  time,  so  that  no 
albumin  contained  in  the  tissues  was 
consumed — acetone,  diacetic  acid,  and 
beta-oxybutyric  acid  were  constantly 
excreted  with  the  urine;  the  diet  was 


free  from  carbohydrates;  when,  also, 
the  quantity  of  proteids  was  some- 
what reduced  the  sugar  disappeared 
after  twenty-four  hours;  the  weight 
of  the  body  was  maintained,  but 
acetone  and  diacetic  acid  were  still 
excreted  (Magnus-Levy). 

Carbonate  of  soda  augmented  the 
quantity  of  acetone  excreted,  without 
diminishing  the  quantity  of  oxybuty- 
ric  acids.  When,  in  periods  of  twenty- 
four  hours,  no  food  at  all  was  taken, 
acetonuria  was  greatly  increased. 
Ingestion  of  carbohydrates  dimin- 
ished the  acetonuria,  even  in  persons 
suffering  from  diabetes;  levulose, 
milk,  and  sugar  have  the  same  prop- 
erty; glycerin,  also,  as  observed  by 
Hirschfeld.  The  addition  of  fat  to 
the  food  has  no  power  to  arrest  the 
acetonuria. 

Hirschfeld  found  that  when  he  put 
two  individuals  on  light  diet,  consist- 
ing only  of  proteids  and  fat,  diminu- 
tion of  albumin  of  the  body,  as  well 
as  acetonuria,  was  produced.  When 
carbohydrates  were  added  to  the  food 
the  acetonuria  diminished,  and  that  to 
a  much  greater  degree  than  the 
diminution  of  albumin.  Ingestions  of 
fat  had  absolutely  no  influence  in 
diminishing  acetonuria,  although  it 
diminished  the  loss  of  nitrogen.  Ace- 
tonuria is  more  marked  when  the 
albuminous  food  is  scarce  than  when 
it  is  given  in  great  quantities.  The 
ingestion  of  carbohydrates  has  an 
extraordinarily  rapid  effect  on  the 
production  of  acetonuria,  the  quantity 
of  acetone  being  considerable  within 
two  hours. 

Experiments  in  persons  who  were 
almost  starving  have  proved  that  a 
moderate  quantity  of  carbohydrates 
was  sufficient  to  bring  about  marked 
diminution  of  acetonuria  in  spite  of 


ACETONURIA    (LEVISON  AND  ERLANDSEN). 


237 


the  considerable  loss  of  all)umin  and 
fat  which  still  took  place. 

Geelmuyden,  from  his  experiments 
on  rabbits  and  dogs  already  men- 
tioned, reached  the  conclusion  that 
acetone  is  formed  in  the  tissues,  not 
in  the  kidneys ;  that  the  kidneys  give 
passage  to  the  acetone,  even  when 
their  blood  contains  a  very  small 
quantity  of  it,  and  that  pathological 
acetonuria  is  not  caused  by  a  defect 
of  disintegration  of  acetone  in  the 
body,  but  by  a  disorder  of  the  general 
metabolism  leading  to  the  formation 
of  an  anomalous  large  quantity  of 
acetone.  Geelmuyden  has  further 
conducted  a  series  of  experiments  in 
healthy  individuals  (medical  stu- 
dents) put  on  different  scales  of  diet, 
which  were  strictly  controlled.  As 
all  observers  did,  Geelmuyden  found 
that  when  a  person  was  put  on  exclu- 
sive flesh  diet  acetonuria  appeared, 
and  at  the  same  time  the  body  lost 
albumin  as  w^ell  as  fat;  when  large 
quantities  of  proteids  were  ingested, 
acetonuria  was  less  considerable  than 
when  less  albumin  was  given.  Com- 
plete starvation,  an  exclusive  fat  diet, 
and  a  diet  of  proteids,  with  the  addi- 
tion of  a  great  quantity  of  fat,  cause 
a  very  considerable  amount  of  acetone 
to  be  excreted.  As  exclusive  diet  of 
fat  and  complete  starvation  give  rise 
to  the  excretion  of  the  largest  quan- 
tity of  acetone,  it  seems  that  acetone 
is  formed  by  disintegration  of  fat,  and 
that  in  this  respect  there  is  no  dif- 
ference between  the  fat  of  the  food 
and  that  of  the  tissues.  Carbohy- 
drates have  a  great  power  to  check 
the  excretions  of  acetone;  when 
individuals  were  put  on  a  diet  without 
carboh3^drates  and  secreted  urine  con- 
taining a  great  quantity  of  acetone, 
the  acetonuria  disappeared  in  a  few 


hours  when  carbohydrates  were  given. 
From  150  to  200  grams  of  carbohy- 
drates per  day  are  required  to  check 
an  already  existing  alimentary  ace- 
tonuria. 

In  the  opinion  of  Geelmuyden,  ace- 
tonuria occurs  when  carbohydrates 
are  not  ingested  in  sufficient  amount, 
and  acetone  is  formed  by  the  disin- 
tegration of  fat,  either  of  that  of  the 
tissues  or  of  that  contained  in  the 
food.  Schwarz  and  Waldvogel  saw 
also  an  increase  of  acetonuria  follow- 
ing the  fat  introduction  per  os. 

PRELIMINARY  TESTS  FOR 
ACETONE.— With  an  alkaline  solu- 
tion of  sodium  nitrocyanide  (of  a 
slightly  red  hue)  acetone  gives  a 
ruby-red  color,  changing,  after  some 
time,  to  yellow,  and,  after  acidify- 
ing with  acetic  acid  and  boiling,  to 
greenish  violet. 

The  cyanide  of  soda  test,  after  Le- 
gal or  le  Nobel  (see  below),  may  be 
employed  as  preliminary  test;  but, 
to  make  the  presence  of  acetone  posi- 
tive, it  is  necessary  to  separate  it  from 
the  urine  by  distillation.  As  the  boil- 
ing point  of  acetone  is  low  (56.3°  C), 
this  may  be  done  at  a  low  tempera- 
ture, and  the  use  of  a  water  bath  is 
recommended. 

Legal's  Test. — To  10  c.c.  of  urine 
a  small  crystal  of  nitrocyanide  of  soda 
or  some  drops  of  a  freshly  made  solu- 
tion of  this  reagent  are  added;  the 
fluid  is  rendered  strongly  alkaline  by 
a  30  per  cent,  solution  of  caustic 
soda  or  potash.  When  acetone  is 
present  a  beautiful  red  color  will  ap- 
pear, which  will  change  onty  after 
some  time  to  yellow;  the  red  color 
produced  in  the  same  manner  by 
creatinin  becomes  yellow  sooner.  Le- 
gal adds  thatj  when  acetone  is  pres- 
ent and  the  urine,  shortly  after  the 


238 


ACETONURIA    (LEVISON  AND  ERLANDSEN). 


addition  of  the  solution  of  soda,  is 
neutralized  with  acetic  acid^  the  urine 
assumes  a  purple-red  color,  and,  when 
diluted  with  water^  a  crimson  hue. 
When  the  acetic  acid  is  floated  on 
the  urine  a  crimson  ring  will  appear 
at  the  point  of  contact,  and,  when 
much  acetone  is  present,  the  color  of 
the  ring-  will  be  purplish  red. 

Legal's  test  is  rendered  simpler  and 
more  reliable  by  substituting  ammonia 
for  the  sodium  hydrate.  This  avoids 
the  disturbing  creatin  reaction.  The 
urine  to  be  tested  is  treated  with  glacial 
acetic  acid  and  then  with  a  few  drops 
of  a  freshly  prepared  solution  of  sodium 
nitroprussid ;  a  few  cubic  centimeters 
of  ammonia  are  then  cautiously  poured 
on  top  of  the  mixture.  In  case  of  the 
presence  of  acetone,  a  bright-violet 
ring  appears  at  the  point  of  contact. 
The  violet  ring  grows  brighter  and 
brighter  without  spreading  wider,  irre- 
spective of  the  quantities  used  in  the 
test-tube  or  conical  glass.  The  reaction 
was  most  distinct  in  the  writer's  tests 
when  15  c.c.  of  urine  and  from  0.5  to 
1  c.c.  of  acetic  acid  _  were  used.  Ace- 
tone, 0.025  per  cent.,  is  readily  detected 
by  this  test.  Alcohol  and  aldehyde  do 
not  give  the  reaction.  Lange  (Miinch. 
med.  Woch.,  Bd.  liii,  Nu.  36,  1906). 

Le  Nobel's  Test.  —  Le  Nobel  and 
Fehr  hold  that  Legal's  test  is  only 
reliable' when  much  acetone  is  pres- 
ent, and  that,  when  there  is  only  a 
small  quantity  of  it  in  the  urine,  the 
test  may  be  fallacious,  since  other 
substances  contained  in  the  urine  can 
produce  a  red  color  with  the  nitro- 
cyanide  of  soda.  The  most  charac- 
teristic point  of  the  test  is,  according 
to  Fehr,  the  appearance  of  the  violet 
hue,  which  causes  the  red  color  to 
become  crimson  or  purple,  and  not 
pure  red. 

Le  Nobel  proposes  to  substitute  a 
solution  of  ammonia  for  the  solution 
of   soda,   when   the   test   is,   in   other 


respect,  made  according  to  the  indi- 
cations of  Legal;  the  fluid  containing 
acetone  is  not  immediately  colored, 
Imt  after  some  time,  when  the  liquid 
is  shaken  with  air  or  some  drops 
of  a  strong  acid  added  (the  alka- 
line reaction  being  maintained),  the 
fluid  takes  a  rose-red  color,  increas- 
ing gradually  and  changing  after 
some  time  to  violet  wine  red.  By 
heating  the  fluid  the  color  disap- 
pears, but  returns  on  cooling  down ; 
when  boiled  with  acids  it  changes 
into  greenish  violet.  Le  Nobel's  test 
is  more  delicate  than  Legal's,  and 
will  reveal  0.00025  gram  of  acetone. 
Lange  thinks  the  contact  reaction 
gives  a  more  distinct  picture  than 
the  mass  reaction,  and  modified  le 
Nobel's  test  in  that  direction:  15  cm. 
of  urine  are  mixed  in  a  reagent  glass 
with  0.5  to  1  c.c.  of  acetic  acid  and  a 
few  drops  of  solution  of  sodium  nitro- 
prusside.  On  floating  a  small  amount 
of  ammonia  upon  this  mixture  an 
intense  violet  ring  develops  at  the 
point  of  contact. 

When  15  c.c.  of  urine  are  mixed  in  a 
reagent  glass  with  from  0.5  to  1  c.c. 
of  acetic  acid,  and  a  few  drops  of  a 
freshly  prepared  solution  of  sodium 
nitroprusside  are  added,  upon  floating 
a  small  amount  of  ammonia  upon  this 
mixture  an  intense  violet  ring  develops 
at  the  point  of  contact  if  acetone  is 
present.  The  test  will  detect  acetone 
in  a  %oo  per  cent,  solution.  This  is 
merely  a  convenient  modification  of  the 
le  Nobel  reaction,  and  has  the  advan- 
tage over. Legal's  test  of  not  reacting 
to  creatinin.  The  writer  thinks  the 
contact  reaction  gives  a  more  distinct 
picture  than  the  mass  reaction.  It  has 
an  advantage  over  the  iodoform  reac- 
tion in  that  alcohol  and  aldehyde  do 
not  give  it.  It  is,  however,  not  nearly 
so  sensitive  as  the  latter.  Lange 
(Miinch.  med.  Woch.,  Bd.  liii,  S.  1764, 
1906). 


ACETONITRIA    (LRVISON  AND  ERLANDSEN). 


239 


Jackson  Taylor  also  modi  lied  le 
Nobel's  test.  lie  adds  stron,y  am- 
monia to  a  fresli-])repared  Solntion 
of  sodinm  nitroprusside  and  urine. 
The  ammonia  solution  remains  on 
the  top.  There  appears — if  acetone 
be  present — a  well-marked  and  abso- 
lutely characteristic  ring-  of  magenta 
(or  petunia)  within  one  to  three 
minutes,  and  gradually  spreads  up- 
ward, pervading  the  whole  of  the 
ammonia  solution  if  acetone  is  pres- 
ent in  considerable  amount. 

Fehr's  Test.  —  Fehr  also  employs 
the  test  after  the  method  of  Legal, 
but  proposes,  wdien  the  color  of  the 
urine  after  the  addition  of  solution 
of  soda  is  passing  from  dark  red  to 
yellow,  to  float  some  drops  of  acetic 
acid  on  the  urine.  When  the  test- 
tube  is  slightly  rotated  so  that  only 
a  small  quantity  of  the  acid  mingles 
with  the  urine,  a  beautiful  violet  color 
will  appear  wdien  acetone  is  present, 
the  intensity  of  the  color  being  pro- 
portionate to  the  quantity  of  acetone 
contained  in  the  urine. 

Chautard's  Test.  —  Romine  recom- 
mends, as  a  reliable  test  for  acetone 
in  the  urine,  a  solution  of  fuchsin 
(1:2000)  into  which  a  current  of 
sulphurous  acid  gas  has  beeen  passed. 
This  rapidly  decolorizes  the  liquid 
and  causes  it  to  assume  a  clear  yel- 
low tint,  wdiich  is  permanent  and 
unaffected  by  an  excess  of  acid.  A 
few  drops  of  such  a  solution,  added 
to  a  urine  containing  acetone,  pro- 
duce a  deep  violet  color.  The  test 
is  delicate  enough  to  allow  the  de- 
tection of  1  part  of  acetone  in  1000  of 
urine. 

DEFINITE  TESTS  FOR  ACE- 
TONE.— When  no  very  great  quan- 
tity of  acetone  is  found  in  the  urine 
it   is   absolutely   necessary   to   distill 


tlie  urine  and  to  test  the  distillate 
with  the  different  reagents.  The  dis- 
tillation of  200  to  300  c.c.  of  urine 
(always  fresh,  since  acetone  can  dis- 
appear when  the  urine  has  to  stand 
hours  in  a  warm  place)  is  made  in 
a  water  bath,  and  a  tem])erature  of 
56°  to  58°  C.  employed.  No  acid 
need  be  added  to  the  urine  before 
distillation,  as  the  acetone  becomes 
distilled  very  well  without  acid  and 
the  acid  might  disintegrate  other  sub- 
stances present  and  thus  cause  the 
formation  of  acetone.  There  is  no 
reason  why  special  care  should  be 
taken  lest  a  small  amount  of  ammo- 
nia be  distilled  with  the  acetone. 
The  distillation  is  only  continued 
until  a  sufficient  quantity  of  fluid  for 
the  different  tests  to  be  employed 
has  passed  over  into  the  recipient. 
The  distillation  is  then  subjected  to 
the  following  tests  :— 

Lieben's  Iodoform  Test. — To  a  few 
c.c.  of  the  distillate  a  few  drops  of  a 
solution  of  potassium  and  some  drops 
of  a  solution  of  iodine  and  iodide 
of  potassium  are  added,  the  solution 
of  potassium  being  added  in  excess. 
Wlien  acetone  is  present,  a  thick, 
3^ellow  precipitate  of  iodoform  will 
immediately  form.  This  test  will  re- 
veal 0.01  mg.  By  heating,  the  iodo- 
form evaporates  and  accumulates  on 
the  sides  of  the  test-tube  in  the  form 
of  small  yellow  plaques,  consisting 
of  the  characteristic  crystals  (hex- 
agonal plaques  and  stars)  of  iodoform. 
The  most  serious  objection  to  Lie- 
ben's test  is  that  many  (at  least  sev- 
enteen) other  substances,  and  espe- 
cially alcohol,  may  give  the  same 
result. 

The  iiiost  satisfactory  test  for  acetone 
in  the  urine  is  Lieben's.  It  is  performed 
by  adding  a  few  drops  of  Lugol's  solu- 


240 


ACETONURIA    (LEVISON  AND  ERLANDSEN). 


tion  to  the  first  10  c.c.  obtained  by  dis- 
tilling 400  c.c.  of  fresh  urine,  then  add- 
ing sodium  hydroxide  solution  until 
the  brown  color  disappears.  In  the 
presence  of  acetone  a  milky  precipitate 
of  iodoform  is  produced,  and  may  be 
recognized  by  its  violet  coloration  with 
caustic  soda  and  thymol,  or  by  its  yel- 
low hexagonal  crystals  under  the  mi- 
croscope. Ronsse  (Annales  de  Gyn.  et 
d'Obstet.,  Mar.,  1900). 

Gunning's  Test. — Gunning  modified 
Lieben's  test  by  using  a  solution  of 
ammonia  and  tincture  of  iodine.  Le 
Nobel  prefers  to  use  a  solution  of 
ammonia  and  iodine  dissolved  in  io- 
dide of  ammonium;  this  certainly  is 
the  best  way  to  make  the  iodoform 
test,  as  no  alcohol  is  added  with 
the  reagents.  According  to  le  Nobel, 
0.001  mg.  of  acetone  can  be  detected 
by  this  testj  but  von  Jaksch  could 
only  detect  acetone  by  it  when  pres- 
ent in  a  quantity  of  0.1  mg.  Errors 
caused  by  the  presence  of  alcohol 
and  aldehyde  are  avoided  by  this  test. 

Reynold's  Test.  —  Freshly  precipi- 
tated oxide  of  mercury  is  dissolved 
by  acetone  in  the  presence  of  alkali. 
Le  Nobel  prefers  to  make  the  test 
by  precipitating  a  solution  of  per- 
chloride  of  mercury  with  an  alcoholic 
solution  of  caustic  potash,  added  until 
the  mixture  gives  a  strong  alkaline 
reaction ;  then  the  fluid  containing 
acetone  is  added  and  the  whole  well 
shaken  in  a  test-tube.  The  fluid  is 
then  filtered  and  care  taken  that  the 
filtrate  be  perfectly  limpid.  The  com- 
bination of  acetone  and  oxide  of  mer- 
cury in  the  filtrate  can  be  detected  by 
chlorate  of  stannum  or  by  floating 
some  drops  of  the  filtrate  on  a  solution 
of  sulphide  of  ammonium :  where  the 
two  liquids  touch  each  other  a  black 
ring  will  appear.  By  means  of  this 
test  0.01  mg.  of  acetone  is  revealed, 


but  aldehyde  is  also  able  to  dissolve  a 
rather  considerable  quantity  of  mer- 
curic oxide. 

The  Nitrocyanide  Test. — This  test 
is  made  with  the  distillate  quite  in  the 
same  manner  as  with  the  urine,  either 
after  the  method  of  Legal  or  after  le 
Nobel's  modification  of  it.  This  test 
is  less  delicate,  and  the  phenols,  which 
possibly  might  have  passed  over  into 
the  distillate,  are  apt  to  give  the  same 
color  as  the  acetone;  the  test,  there- 
fore, gives  no  proof  of  the  presence  of 
the  latter  substance. 

Penzoldt's  Indigo  Test.  —  Baeyer 
and  Drewsen  found  that  acetone 
forms  indigo  blue  with  orthonitroben- 
zaldehyde.  Penzoldt  has  employed 
this  reagent  by  dissolving  crystals 
of  orthonitrobenzaldehyde  in  boiling 
water;  on  cooling  down  the  aldehyde 
forms  a  white,  milky  cloud;  the  fluid 
which  is  to  be  tested  is  now  added  and 
the  mixture  rendered  alkaline  with  a 
solution  of  sodium  hydrate.  When 
acetone  is  present  a  yellow  color  will 
appear,  which  changes  to  green  and, 
after  ten  minutes,  to  indigo;  it  also 
forms  an  indigo-blue  precipitate.  Very 
small  quantities  of  acetone  may  be  de- 
tected by  shaking  the  mixture  with  a 
few  drops  of  chloroform.  When  left 
quiet  for  some  time  the  chloroform 
takes  a  blue  color  and  sinks  to  the 
bottom  of  the  test-tube. 

According  to  Penzoldt,  acetone  is 
revealed  by  this  test  in  a  solution  of  1 
to  2000.  According  to  von  Jaksch,  the 
smallest  quantity  of  acetone  revealed 
by  it  is  1.6  mg.  Aldehyde  acetophe- 
none  and  other  substances  form  indigo 
in  the  same  way  as  acetone,  but  the 
color  is  not  so  marked. 

Malerba's  Test.  —  Malerba  found 
that  a  3^  per  cent,  solution  of  parami- 
domethylaniline   with   acetone  gives    a 


ACETONURIA    (LEVISON  AND  ERLANDSEN). 


241 


reddish  color,  changing  into  violet  and 
hlue-red. 

Riegler  describes  the  fc^llowing  test : 
15  cm.  of  urine  are  acidulated  with 
5  to  10  drops  of  concentrated  sul- 
phuric acid.  When  2  to  3  c.c.  of  an 
aqueous  solution  of  iodic  acid  are 
added,  an  intense  pink  color  will  ap- 
pear, which  is  not  taken  up  by  chloro- 
form. The  test  is  said  to  be  specific 
and  active  where  Legal's  test  fails. 

.  Frommer  renders  the  urine  strongly 
alkaline  with  potassium  hydrate  and 
adds  several  drops  of  a  10  per  cent, 
solution  of  salicylic  aldehyde,  and 
heats  to  70°  C.  A  purple  ring  appears 
if  the  reaction  is  positive. 

Miscellaneous  Tests. — With  bisul- 
phite of  soda,  acetone,  as  well  as  the 
aldehydes,  combines  to  a  crystallic 
compound  in  thin  flakes  resembling 
those  of  cholesterin,  even  by  micro- 
scopic examination  (Limpricht). 

Acetone  in  an  alkaline  solution  com- 
bines with  iodine  to  form  iodoform. 

Freshly  precipitated  oxide  of  mer- 
cury is  dissolved  by  acetone.  Indigo 
is  formed  when  acetone  is  combined 
with  orthonitrobenzaldehyde  in  an 
alkaline  solution.  (Bae3^er  and  Drew- 
sen.) 

From  what  has  just  been  stated  it 
will  become  apparent  that  not  one  of 
the  tests  is  specific  for  acetone  alone. 
To  be  quite  sure  that  acetone  is 
contained  in  the  distillate,  it  is  nec- 
essary to  try  successively  by  all  the 
tests,  and  only  when  all  tests  give 
positive  result  is  the  presence  of 
acetone  proved. 

A.  E.  Taylor  is  of  the  opinion  that 
only  the  tests  described  by  Stock  and 
Deniges  are  really  good  and  reliable 
and  should  replace  the  tests  with 
Lugol's  solution,  mercuric  oxide  and 
sodium   nitroprusside. 


The  only  two  really  good  tests  for 
acetone  in  the  urine  are  that  of  Stock, 
described  in  1899,  and  that  of  Deniges, 
described  in  1898.  These  are  certain  in 
their  results  and  easy  of  execution,  and 
should  replace  the  fallacious  tests  with 
Lugol's  solution,  mercuric  oxide  and 
sodium  nitroprusside.  The  two  tests 
agree ;  the  writer  has  never  had  the 
Stock  test  present  without  the  Deniges 
test  being  also  positive.  The  Stock  test 
is  less  sensitive  than  the  other,  but  this 
is  considered  an  advantage  for  prac- 
tical purposes.  The  author  has  often 
found  acetone  present  by  these  tests 
without  obtaining  the  reaction  for 
diacetic  acid,  for  which  he  also  gives 
the  method;  but  he  has  never  found 
diacetic  acid  present  without  acetone. 
A.  E.  Taylor  (Jour.  Amer.  Med.  Assoc, 
Mar.  17,  1909). 

The  quantitative  estimation  of  the 
acetone  bodies  is  often  most  impor- 
tant as  an  indicator  of  the  degree  of 
derangement  of  metabolism  and  aci- 
dosis that  may  be  present. 

Von  Jaksch  has  tried  to  employ  the 
nitrocyanide  test  for  a  quantitative 
estimation  of  the  acetone,  and  the 
iodoform  test  has  been  recommended 
by  Messinger  and  Huppert  for  the 
same  purpose.  The  quantity  of  iodine 
used  to  form  iodoform  with  the  ace- 
tone is  measured  (titrated),  and  the 
quantity  of  the  acetone  present  in  the 
solution  calculated  by  it  also;  but, 
although  Engel  and  Devoto  are  of  the 
opinion  that  it  is  possible  to  make 
pretty  accurate  estimations  in  this 
way,  methods  for  quantitative  estima- 
tion of  the  actone  are  not  to  be  relied 
upon,  as  it  is  impossible  to  avoid 
errors  caused  by  the  presence  of  sub- 
stances which  are  influenced  by  the 
tests  in  the  same  way  as  the  acetone. 

Diacetic  acid  (CiHeOs^CHs— CO 
_CH2— COOH)  may  be  revealed  in 
the  urine  by  the  aid  of  a  solution  of 
perchloride  of  iron  (Gerhardt's  test), 

1—16 


242        ACETONURIA    (LEVISON  AND  ERLANDSEN). 


ACETOZONE. 


which,  with  diacetic  acid,  produces 
a  dark  wine-red  color.  The  test  is 
made  by  adding  a  solution  of  per- 
chloride  of  iron  as  long  as  a  precipi- 
tate of  phosphates  of  iron  is  formed. 
The  mixture  is  then  filtered  and  some 
drops  of  perchloride  are  added  to  the 
filtrate.  When  diacetic  acid  is  present, 
the  filtrate  takes  a  deep-red  color, 
which  vanishes  in  twenty-four  hours, 
and  more  rapidly  after  addition  of 
strong  acids.  Von  Jaksch  has,  by  a 
colorimetric  method  based  on  this  test, 
tried  to  make  an  approximate  estima- 
tion of  the  quantity  of  diacetic  acid 
contained  in  the  urine,  but  newly 
passed  urine  can  alone  be  used  for  the 
search  of  diacetic  acid,  as  this  acid, 
after  some  time — twenty-four  to  forty- 
eight  hours — will  disappear  from  the 
urine.  Diacetic  acid  can  be  isolated 
from  the  urine  by  adding  a  few  drops 
of  sulphuric  acid  and  shaking  the 
mixture  with  ether.  When  diacetic 
acid  is  present,  it  is  dissolved  in  the 
ether  and  can  be  detected  by  the  per- 
chloride of  iron  test. 

Beta-oxybutyric  acid  (C4H8O3)  is 
also  found  sometimes  in  the  urine  of 
fever  patients,  as  well  as  in  diabetes, 
with  acetone  and  diacetic  acid.  This 
may  also  be  the  case  in  the  dyspepsia 
of  alcoholism  and  in  carcinoma  of  the 
stomach,  scarlatina,  measles  and  scor- 
butus. When  beta-oxybutyric  acid  is 
cautiously  oxidated,  acetone  is  found. 

For  general  practice  the  exact  quan- 
titative determination  of  the  acetone 
bodies  is  rather  complicated.  To 
overcome  this  difficulty,  Stuart  Hart 
(1908)  devised  a  procedure  based  on 
the  delicacy  of  the  well-known  test- 
tube  reactions  in  urine.  The  urine  is 
first  tested  for  Gerhardt's  reaction.  If 
positive,  we  know  the  acetone  bodies 
to  be  present  in  excess  of  0.2  Gm.  per 


liter.  If  the  reaction  is  very  strong, 
the  test  solution  is  diluted  wath  dis- 
tilled water  until  the  color  approxi- 
mates that  of  the  standard  ferric 
chloride  solution,  and  this  dilution, 
when  compared  in  one  of  the  author's 
tables,  gives  the  amount  in  Gm.  per 
liter.  If  Gerhardt's  reaction  is  nega- 
tive, Arnold's,  Legal's  and  Lieben's 
tests  are  tried  in  the  order  named.  A 
positiA^e  Arnold  reaction  indicates  Ca 
0.1  Gm.  per  liter;  positive  Legal  reac- 
tion Ca  0.03  Gm.  per  liter.  If  only 
Lieben's  test  is  positive,  the  amount 
of  acetone  is  within  the  normal  limits. 

F.  Levi  SON 

AND 

A.  Erlandsen, 

Copenhagen. 

ACETOZONE,  a  germicide  and  de- 
odorant (accepted  by  the  A.  M.  A.  Coun- 
cil) formerly  known  as  bensozone,  is  a 
mixture  of  acetylbenzoyl  peroxide  and  an 
inert  absorbent  powder.  It  was  introduced 
by  Freer  and  Novy,  of  the  University  of 
Michigan.  Its  properties  resemble  those 
of  hydrogen  peroxide,  though,  according 
to  its  discoverers,  it  is  over  one  hundred 
times  more  active  as  a  germicide. 

Acetozone,  in  its  original  form,  occurs 
as  white  shining  crystals,  but  is  marketed 
in  the  form  of  a  powder.  The  latter  should 
be  kept  perfectly  dry,  but  it  should  not  be 
exposed  to  heat,  which  decomposes  and 
volatilizes  it.  It  is  also  rapidly  decom- 
posed by  organic  substances  and  should 
not  be  administered  after  a  meal. 

Modes  of  Administration. — Acetozone  is 
usualljr  employed  in  the  following  manner: 
''Add  the  powder  to  warm  water  in  the 
proportion  of  IS  grains  to  the  quart;  shake 
vigorously  for  five  minutes,  and  allow  to 
stand  for  about  two  hours.  Decant  off  the 
liquid  as  required.  If  the  patient  objects 
to  the  taste,  a  little  extract  of  orange  or 
lemon,  or  orange  or  lemon  juice,  ginger 
ale,  carbonated  water,  or  fruit  syrup  may 
be  added  to  each  dose  as  taken."  It  may 
also  be  given  in  capsules,  but  followed  at 
once  by  a  copious  draught  of  water. 


ACETPIIENETIDIN    (SAJOUS). 


243 


It  is  soluble  in  water  to  the  extent  of 
1:  1000  to  10,000;  in  its  crystalline  form  in 
oils  to  the  extent  of  about  3  per  cent,  and 
slightly  soluble  in  alcohol,  ether,  and 
chloroform,  but  all  these  solvents  grad- 
ually decompose  it.  This  does  not  apply 
to  neutral  petroleum  oils,  however,  and 
an  "ai-clo::oiic  iiilnilaiit"  is  available  which 
contains  1  part  of  acetozone,  14  part  of 
chloretone,  and  98.5  parts  of  refined  liquid 
petroleum.  It  may  be  given  in  an  ointtnent, 
using  solid  or  liquid  petrolatum  as  excip- 
ient,  beginning  with  >^  per  cent,  strength. 
An  aqueous  solution  may  be  used  as  spray 
and  as  a  deodorizer  and  antiseptic  for  stools, 
sputum,  etc. 

Therapeutics. — Acetozone  is  used  for  its 
marked  oxidizing  and  germicidal  action 
mainly  for  the  treatment  of  diseased 
mucous  membranes.  It  has  been  credited 
with  a  favorable  action  in  typhoid  fever, 
the  main  effect  being  decrease  of  the  fetor 
of  the  stools,  subsidence  of  the  tympanites 
and  diarrhea,  and  prevention  of  hyper- 
P3^rexia.  Good  results  have  been  obtained 
in  Asiatic  cholera.  In  ophthalmology,  a 
solution  of  1  grain  to  2  ounces  of  water, 
instilling  1  drop  or  2  every  hour,  has  been 
found  useful  in  corneal  infections.  In 
laryngology,  tonsillitis  and  atrophic  rhi- 
nitis have  seemed  to  be  beneficially  in- 
fluenced. This  applies  also  to  infected 
wounds,  gonorrhea,  and  chancroid.  It  has 
been  found  an  excellent  deodorant  in  gan- 
grene and  malignant  small-pox.  S. 

ACETPARAMIDOSALOL. 

See  Salophen. 

AGETPHENETIDIN.- 

(acetphenetidinum;  para-acetpheneti- 
din),  commonly  known  under  the  pro- 
prietary name  of  pJienacetin,  is  a  coal- 
tar  product,  obtained  by  treating  para- 
phenetidin  with  glacial  acetic  acid.  It 
is  an  acetyl  derivative  [C6H4.  OC2H5. 
NHCH;;CO]  of  para-amidophenol. 
,  PROPERTIES.— Acetphenetidin  oc- 
curs in  the  form  of  a  white,  odorless, 
and  practically  tasteless  powder,  com- 
posed of  small,  needle-like  or  scaly  crys- 
tals. 


DOSE.— Five  to  10  grains  (0.32  to 
0.65  gram)  in  adults ;  1  to  5  grains  (0.065 
to  0.32  gram),  according  to  age,  in  chil- 
dren. The  maximum  amount  to  be 
given  in  twenty-four  hours,  according  to 
Pouchet,  is  30  to  45  grains  (2.0  to  3.0 
grams),  which  should  be  distributed 
during  the  day  in  several  doses,  each  not 
exceeding  7%  grains  (0.5  gram).  The 
tendency  is  toward  a  marked  decrease 
of  this  amount. 

Out  of  297  observers  using  acet- 
phenetidin, 10,  or  33  per  cent.,  em- 
ployed less  than  2  grains  as  a  minimum 
dose  for  adults ;  90,  or  30.3  per  cent., 
employed  2.5  grains  or  less  as  a  mini- 
mum dose ;  188,  or  63.3  per  cent,  em- 
ployed from  3  to  S  grains  as  a  minimum 
dose ;  89,  or  29.9  per  cent.,  used  doses 
exceeding  5  grains,  while  208,  or  70 
per  cent,  never  exceeded  a  dose  of  5 
grains. 

An    examination    of    a    number    of 
prescriptions  for  adults  on  file  in  vari- 
ous pharmacies   in   Washington,   D.   C, 
showed  that  the  average  dose  of  acet- 
phenetidin  prescribed   was    1.92   grains. 
Kebler,  Morgan,  and  Rupp  (U.  S.  Dept 
of  Agricul.,  Bureau  of  Chemistry,  Bull. 
No.  126,  July  3,  1909). 
MODES   OF  ADMINISTRA- 
TION.— Acetphenetidin   is    almost  in- 
soluble   in    cold    water   (1    grain    in  2 
ounces),  more  freely  soluble  in  boiling 
water   (1  grain  in  1  dram),  and  read- 
ily so  in  alcohol  (1  grain  in  12  minims)  ; 
it  will  also  dissolve  in  glycerin  and  lac- 
tic acid. 

Being  almost  tasteless,  it  is  easily 
taken  in  powder  form ;  it  can  also  be 
given  in  capsules,  cachets,  or  tablets. 
When  combined  with  other  remedies  in 
liquid  preparations  it  is  best  kept  in 
solution  by  dilute  alcohol.  Thus  a  mix- 
ture of  acetphenetidin,  sodium  bromide, 
and  caffeine  in  the  adjuvant  elixir  is 
frequently  prescribed  for  the  relief  of 
headache.  A  good  formula  is  the 
following : — 


244 


ACETPHENETIDIN    (SAJOUS). 


R.  Acetphenetidini   gr.  xv  (1.0  Gm.). 

Caffeines  citrates gr.  viij  (0.5  Gm.). 

Sodii  bromidi  3j  (4.0  Gm.). 

Elixir  adjuvantis  ...    Sj  (30.0  c.c). 
M.     Sig. :     Two   teaspoonfuls,    repeated   if 
necessary.     Shake  well. 

Where  nausea  and  vomiting  accom- 
pany headache,  oral  administration  be- 
ing, therefore,  unsuitable,  acetpheneti- 
din  may  be  administered  by  the  rectum 
in  1  or  2  drams  of  water  (Brunton). 

Acetphenetidin  is  sometimes  used  lo- 
cally in  powder  form  or  in  an  ointment 
or  alcoholic  preparation. 

INCOMPAT IBILITIES.— Acet-' 
phenetidin  is  incompatible  with  iodine, 
nitric  acid,  and  oxidizing  agents  gener- 
ally; also  with  chloral  hydrate,  phenol, 
and  salicylic  acid. 

CONTRAINDICATIONS.— These 
are  the  same  as  those  of  acetanilide 
{q.v.),  though  the  dangers  from  its  use 
are  less  marked  than  with  the  latter 
drug.  It  is  advisable  not  to  employ  it 
in  cases  of  heart  disease,  pulmonary 
tuberculosis,  grave  anemia,  or  in  per- 
sons markedly  enfeebled  from  any 
other  cause. 

PHYSIOLOGICAL  ACTION.— 
As  Antipyretic. — Acetphenetidin  is  the 
safest  and  most  frequently  employed 
of  antipyretic  remedies.  In  common 
with  acetanilid,  it  has  little  or  no  influ- 
ence on  the  temperature  of  normal  indi- 
viduals in  therapeutic  doses,  but  causes 
a  fall  in  febrile  cases.  According  to 
Crombie  and  Hirschfelder,  the  greatest 
reduction  is  not  produced  until  three  or 
four  hours  after  administration.  The 
average  decline  may  be  put  down  as 
3.6°  F.  (2°  C;  Manquat).  The  reduc- 
tion may  last  six  to  eight  hours,  and  is 
free  of  unpleasant  effects,  excepting  a 
mild  sweat  (Pesce).  Cerna  and  Carter 
found  that  acetphenetidin  produced  a 
very  slight  fall  of  temperature  during 
the  first  and  second  hours  after  inges- 


tion, and  that  the  effect  reaches  its 
height  in  the  third  hour.  They  believe 
that  the  fall  of  temperature  results 
chiefly  from  a  decrease  in  heat  produc- 
tion, together  with  a  slight  increase  in 
the  heat  dissipation,  less  marked  than 
in  the  case  of  antipyrin.  Probably  the 
delayed  action  of  the  drug  depends  on 
its  insolubility.  It  should  be  mentioned, 
however,  that  certain  authors  describe 
its  effect  as  teing  more  prompt,  and 
comparable  with  that  of  acetanilide. 

With  regard  to  the  manner  in  which 
the  antipyretic  effect  is  produced,  the 
prevailing  belief  is  that  it  depresses  the 
heat-regulating  centers. 

[Viewed  from  my  standpoint,  the  action  of 
acetphenetidin  dififers  only  from  that  of 
acetanilide  {q.v.)  in  that  it  excites  less 
violently  the  sympathetic  center,  owing  to 
its  greater  insolubility.  As  the  sympa- 
thetic center  governs  the  caliber  of  the 
arterioles  (see  "Internal  Secretions,"  vol. 
ii,  1907),  its  excitation  causes  constriction 
of  these  small  vessels  and  a  reduction  of 
the  volume  of  arterial  blood  admitted  into 
the  tissues.  This  entails  a  reduction  of 
temperature  in  the  latter,  (1)  owing  to  the 
lowered  metabolic  activity  which  the  dimi- 
nution of  arterial  blood  in  the  superficial 
tissues  entails,  and  (2)  because  the  adre- 
nals and  the  thyroid,  which  jointly,  as  I 
have  shown,  supply  the  substances  which 
in  the  blood  sustain  oxidation  and  metab- 
olism, are  themselves  rendered  less  active 
by  the  diminished  blood-supply.  It  is 
therefore,  by  exciting  the  sympathetic  center, 
that  acetphenetidin  produces  its  effects.  This 
reduces  heat  production  by  inhibiting  both 
the  functional  activity  of  the  adrenals  and 
thyroid  and  tissue  metabolism.     C.  E.  de  M.  S.] 

As  Analgesic. — Acetphenetidin  is 
considered  to  exert  a  sedative  effect 
upon  the  nervous  system.  Its  anodyne 
influence  is  more  marked  than  that  of 
acetanilide  or  antipyrin.  It  is  believed 
to  depress  the  nerve-centers,  in  common 
with  the  other  antipyretics,  but  it  has 
probably  also  some  action  on  the  sen- 
sory nerves,  since  it  frequently  relieves 


ACETPHENEtlDIN    (SAJOUS). 


245 


neuralgic  pain  without  giving  evidence 
of  any  central  depressant  action  by  the 
production  of  drowsiness  or  mental 
apathy. 

Injected  into  animals,  large  doses  of 
acetphenetidin  are  required  before  its 
effects  on  the  nervous  system  appear. 
Using  doses  of  0.5  to  1  Gm.  per  kilo  of 
body  weight  in  rabbits,  Mahnert  ob- 
served merely  a  muscular  weakness, 
lasting  a  few  hours,  which  he  ascribed 
to  a  depressing  action  on  the  spinal 
cord.  With  doses  of  3  Gm.  per  kilo  he 
obtained  a  short  period  of  spinal  excita- 
tion, followed  by  one  of  complete  motor 
and  sensory  paralysis,  with  loss  of  re- 
flexes and  early  death.  In  frogs  the 
preliminary  spinal  excitation  may  be 
such  as  to  produce  convulsions.  In 
mammals  convulsions  produced  by  the 
antipyretics  may  be  of  cerebral,  spinal, 
or,  possibly,  asphyxial  origin  (Cushny). 
H.  C.  Wood,  Jr.,  and  H.  B.  Wood 
watched  the  effects  of  acetphenetidin 
on  frogs  when  absorbed  through  the 
skin  from  a  saturated  solution.  Like 
Mahnert,  they  noted  a  sluggishness  of 
movement  and  loss  of  muscular  power, 
proceeding  steadily  to  complete  paraly- 
sis, with  final  cessation  of  the  heart 
beats.  In  addition,  they  found  that  the 
motor  nerves  and  the  muscles,  though 
soaked  in  saturated  acetphenetidin  so- 
lution, continued  responsive  to  electric 
stimulation  throughout  the  period  of  ac- 
tion of  the  drug,  and  even  after  death, 
and  concluded,  therefore,  that  the  loss 
of  reflexes  and  paralysis  observed  had 
been  of  spinal  origin.  They  ascertained 
that  doses  of  0.5  Gm.  per  kilo,  injected 
into  the  jugular  vein  of  a  dog,  caused 
death   from  paralysis  of  respiration. 

Local  applications  of  acetphenetidin 
have  some  analgesic  effect. 

[The  reduction  of  pain  is  also  due  to  the 
constriction   of   the   arterioles   the   drug  pro- 


duces. Less  blood  being  admitted  into  the 
painful  area,  the  sensory  nerve  terminals  are 
no  longer  hyperemic,  and  they  cease  to  trans- 
mit painful  impressions. 

The  same  process  explains  all  the  experi- 
mental phenomena  :  the  muscular  sluggish- 
ness, the  paralysis,  the  cardiac  arrest,  etc., 
since  diminution  of  the  blood  supplied  to  a 
tissue  reduces  in  proportion  its  functional 
activity.  The  convulsions  are  due  to  the 
accumulation  of  toxic  wastes  (as  in  epilepsy, 
tetanus,  etc.),  owing  to  imperfect  catabolism, 
the  latter  process  being  under  the  dependence 
of  the  (now  inhibited)  adrenals  and  thyroid. 
C.  E.  DE  M.  S.] 

On  the  Circulation. — Conflicting 
views  have  been  advanced  by  different 
observers  concerning  the  effects  of  the 
drug  on  the  blood-pressure.  Cerna  and 
Carter  found  that,  in  moderate  doses,  it 
caused  a  rise  of  the  arterial  pressure  by 
directly  stimulating  the  heart's  action, 
and  also,  probably,  the  vasomotor  sys- 
tem, while  in  large  doses  it  decreased 
the  pressure,  chiefly  by  its  influence  on 
the  heart.  They  also  state  that  acet- 
phenetidin tends  to  increase  the  pulse 
rate,  mainly  by  cardiac  stimulation,  and 
possibly,  also,  by  influencing  the  cardio- 
accelerator  apparatus,  while  later,  es- 
pecially with  large  doses,  it  decreases 
it  primarily  by  stimulating  the  cardio- 
inhibitory  centers,  and  later  by  depress- 
ing the  heart.  Ott  and  H.  C.  Wood, 
Jr.,  on  the  contrary,  assert  from  their 
experiments  that  acetphenetidin  does 
not  influence  the  blood-pressure.  Mah- 
nert considers  the  drug  to  be  antago- 
nistic to  strychnine  in  its  physiological 
action,  large  doses  producing  paralysis 
of  the  cardiac  and  respiratory  centers. 
In  the  early  stage  of  its  action,  however, 
it  is  believed  to  stimulate  these  centers 
for  a  time. 

[The  influence  on  blood-pressure  noticed 
by  some  observers  is  due  to  the  fact  that 
the  constriction  of  the  arterioles  produced 
by  the  drug  causes  these  vessels  to  impede 
the  flow  of  blood  into  the  capillaries,  and  to 


246 


ACETPHENETiDIN    (SAJOUS). 


cause  the  blood  to  accumulate  behind  the 
obstruction,  thus  causing  a  back  pressure  in 
the  large  vessels.  As  soon  as  the  dose  is 
large  enough  to  inhibit  the  heart's  action  by 
reducing  the  blood  supplied  to  its  walls,  this 
organ  is  unable  to  keep  up  the  pressure — in 
keeping  with  Cerna  and  Carter's  view.  Large 
doses  thus  fail  to  produce  a  rise  of  the 
blood-pressure.     C.  E.  de  M.  S.] 

On  the  Blood. — Alterations  in  the 
blood  are  much  more  rarely  caused  by 
acetphenetidin  in  moderate  doses  than 
by  acetanilide.  The  formation  of  met- 
hemoglobin  has,  however,  been  ob- 
served in  a  few  cases.  According  to 
Cushny,  this  untoward  result  is  due  to 
the  action  of  para-amidophenol,  into 
which  the  drug  is  gradually  decomposed 
in  the  organism.  Cerna  and  Carter 
were  unable  to  produce  methemoglobi- 
nemia in  their  experiments  on  animals. 

Acetphenetidin  is  said  to  have  a 
slightly  stimulating  influence  on  the 
sweat-glands,  which  is  not  possessed  by 
the  other  antipyretics. 

[When  the  dose  is  very  large  or  the 
sympathetic  center  is  abnormally  sensitive, 
the  arterioles  are  sufficiently  contracted  to 
reduce  the  supply  of  blood  to  the  tissues  be- 
low their  normal  needs.  The  blood  is  not 
only  rendered  venous  abnormally  soon  under 
these  conditions  by  the  intense  reducing 
power  of  the  tissues,  but  the  hemoglobin 
molecule  itself  is  broken  down,  methemo- 
globin  being  formed.    C.  E.  DE  M.  S.] 

Elimination. — Acetphenetidin  is  be- 
lieved to  be  eliminated  chiefly  in  an  al- 
tered condition,  losing  its  acetyl  radicle 
in  transit  through  the  organism,  and  ap- 
pearing in  the  urine  as  glycuronates  of 
phenetidin  (Cushny).  The  gastric  and 
pancreatic  juices  being  without  influ- 
ence on  the  drug  m  vitro,  F.  Miiller  be- 
lieves that  the  decomposition  must  oc- 
cur after  it  has  been  absorbed.  Accord- 
ing to  Gueorguievsky,  the  elimination 
by  the  urine  begins  in  twenty  minutes 
and  proceeds  rapidly.  Perchloride  of 
iron  added  to  this  urine  causes  a  Bur- 


gundy red  color  to  appear.  Acetphe- 
netidin may  also  be  eliminated  in  part  by 
the  skin,  since  Hirschmann  not  infre- 
quently found  large  numbers  of  crystals 
precisely  similar  to  those  of  the  drug 
on  the  skin  of  persons  to  whom  it  had 
been  administered. 

UNTOWARD  EFFECTS  AND 
POISONING.— H.  C.  Wood  states 
that  no  symptoms  are  produced  by 
the  therapeutic  dose  of  this  drug. 
Even  large  doses  of  it  have  been 
given  so  often  without  markedly  un- 
pleasant results  that,  in  contrast  with 
acetanilide  and  antipyrin,  it  has  fre- 
quently been  described  as  non-toxic. 
Massive  doses,  however,  and  even  mod- 
erate doses  in  certain  susceptible  indi- 
viduals, have  been  known  to  cause  un- 
toward effects  similar  to  those  of  the 
other  coal-tar  antipyretics.  The  most 
commonly  observed  of  these  have  been 
profuse  sweating,  somnolence,  lassitude, 
sometimes  accompanied  by  nausea,  ver- 
tigo, or  chilliness.  In  more  severe  cases 
there  have  occurred  cyanosis,  beginning 
and  most  marked  in  the  face,  lips,  and 
finger-tips,  then  becoming  general ;  pros- 
tration, vomiting,  palpitation,  dyspnea, 
anxious  expression,  followed  by  col- 
lapse, which  occasionally  is  fatal.  The 
blood  may  be  darkened  by  the  forma- 
tion of  methemoglobin.  The  urine  has 
been  found  to  contain  blood  (Kronig). 
In  a  case  reported  by  Hollopeter  three 
doses,  of  7  grains  each,  of  phenacetin 
sufficed  to  produce  in  a  woman  severe 
precordial  pains,  great  dyspnea,  general 
lividity,  somewhat  dilated  pupils,  and 
collapse,  with  unconsciousness ;  recovery 
took  place  after  a  week.  Cutaneous 
eruptions,  usually  urticarial,  are  some- 
times caused,  though  less  frequently 
than  by  antipyrin.  As  with  acetanilide, 
the  onset  of  the  symptoms  is  frequently 
sudden  and  unexpected,  the  patient  hav- 


ACETPHENETIDIN    (SAJOUS). 


247 


ing    previously    borne    repeated    doses 
without  harmful  effect. 

[All  the  morbid  effects  of  large  doses  of 
acetphenetidin  are  the  result  of  the  excess- 
ive constriction  of  the  arterioles  it  causes. 
The  sweating'  is  due  to  ischemic  relaxation 
of  the  spiral  muscles  of  the  sweat-glands; 
the  vertigo  and  somnolence  to  cerebral 
ischemia;  lassitude  to  the  same  condition 
of  the  muscles;  the  chilliness  and  cyanosis 
to  cutaneous  ischemia  and  the  too  rapid 
conversion  of  arterial  into  venous  blood,  etc. 
C.  E.  DE  M.  S.] 

Case  of  a  woman  suffering  from 
ovaritis  and  acute  dysmenorrhea,  who 
took  5  to  8  cachets  containing  each  10 
grains  (0.65  Gm.)  '  of  acetphenetidin 
in  twenty-four  hours.  She  suddenly 
complained  of  palpitation  of  the  heart ; 
her  face  was  brilliantly  scarlet  with  the 
exception  of  the  bridge  of  the  nose  and 
the  upper  lip,  which  were  markedly  pal- 
lid ;  the  pulse  was  extremely  rapid,  and 
she  also  sufifered  from  headache,  dysp- 
nea, and  diaphoresis.  There  was  no 
urinary  or  gastric  disturbance.  John 
Harold   (Practitioner,  Dec,  1894). 

Two  cases  in  which  acetphenetidin 
caused  dyspnea  and  orthopnea.  In  the 
first  case  15  grains  (1  Gm.)  every  four 
hours  were  taken  for  some  time  with 
impunity,  but  after  thirty-six  hours  the 
patient  repeated  the  dose  in  two  hours, 
the  result  being  marked  shortness  of 
breath  and  extreme  restlessness.  In  the 
second  case  20  grains  (1.3  Gm.)  were 
administered  every  two  hours  until  2 
drams  (8  Gm.)  had  been  taken,  when 
dyspnea  resulted  and  continued  for  an 
hour.  J.  L.  Lackie  (Medical  Press  and 
Circular,  Aug.  28,  1895). 

Fatal  case  of  acetphenetidin  poison- 
ing in  a  boy  17  years  old  suffering  from 
chronic  middle-ear  disease,  who  had 
taken  4  powders,  of  15  grains  each, 
within  three  weeks.  Sepsis  having  set 
in,  a  fifth  dose,  taken  one  evening, 
brought  on  vomiting,  followed  by  gid- 
diness, great  weakness,  and  cyanosis  of 
the  face  and  lips.  The  temperature 
was  102.2°  F.,  the  pupils,  of  medium 
size,  the  pulse  weak,  and  the  pa- 
tient complained  of  headache,  vomiting, 
and    diarrhea.     The    conjunctivae    were 


slightly  yellowish,  and  a  general  icteric 
appearance  followed,  combined  with 
blucness  of  the  lips,  ears,  hands,  and 
feet.  The  blood  contained  red  cells  in 
various  stages  of  dissolution  and  of 
different  sizes  and  shapes.  Particles  of 
hemoglobin  were  set  free  in  the  plasma. 
There  was  marked  leucocytosis.  The 
urine,  obtained  by  catheter,  was  thick, 
dark  reddish  brown  in  color,  later  con- 
taining masses  of  almost  pure  blood. 
Death  occurred  in  two  days,  with  uni- 
versal methemoglobinemia.  G.  Kronig 
(Berl.  klin.  Woch.,  Nov.  18,  1895). 

Eight  grains  of  acetphenetidin  taken 
every  three  hours  for  headache.  After 
the  third  dose,  the  patient  became  very 
ill,  and  his  face  became  pale.  Shiver- 
ing, cold  perspiration,  and  dyspnea  fol- 
lowed. Wheals  developed  on  the  backs 
of  the  hands  and  right  shoulder,  and 
the  face  became  swollen  and  of  a 
mahogany  color.  Recovery  followed. 
W.  A.  Betts  (Brit.  Med.  Jour.,  Jan.  18, 
1896). 

Petechial  eruption  on  the  legs,  fol- 
lowed in  a  week  by  ulceration,  reported 
as  the  result  of  taking  acetphenetidin. 
Upon  stopping  the  drug  the  ulcers 
quickly  healed,  but  after  another  dose 
of  llYi  grains  they  reappeared.  M. 
Hirschfeld  (Deut.  med.  Woch.,  Nu.  31, 
1905). 

The  exhibition  of  15  grains  of  acet- 
phenetidin every  two  hours  for  twenty- 
four  hours  resulted  in  marked  feeble- 
ness, followed  by  symptoms  of  collapse, 
with  faintness,  dizziness,  dyspnea,  cya- 
nosis of  the  limbs,  combined  with  a  gen- 
eral yellowish-gray  color,  pain  over  the 
heart,  nausea,  and  a  rapid,  weak  pulse. 
On  the  following  day  a  macular  erup- 
tion made  its  appearance.  Recovery- 
took  place  in  five  days.  J.  Meurice 
(Ann.  de  la  Soc.  de  Med.  de  Gand.,  No. 
85,  1905). 

Fatal  case  of  poisoning  in  a  woman 
of  50  suffering  from  muscular  rheuma- 
tism, who  had  taken  on  the  same  day 
2  powders  each  containing  15  grains 
of  acetphenetidin  and  3  grains  of 
caffeine  sodiobenzoate.  Marked  pallor 
appeared,  followed  by  profuse  sweating, 
nausea,  vomiting  of  a  cerebral  type,  and 


248 


ACETPHENETIDIN    (SAJOUS). 


restlessness.  An  injection  of  camphor 
and  a  small  dose  of  morphine  were 
given.  On  the  next  day  the  condition 
became  worse,  notwithstanding  cam- 
phor injections  every  two  hours,  am- 
monia, and  an  injection  of  normal 
saline.  In  the  afternoon  the  patient 
became  unconscious.  The  pulse  was 
120;  respirations,  30.  Progressive  cya- 
nosis of  the  face  and  limbs  ended  in 
death  from  vasomotor  paralysis  the 
same  evening.  The  urine  was  of  a 
porter-brown  color,  gave  the  reactions 
for  methemoglobin,  and  showed  evi- 
dence of  parenchymatous  nephritis  in 
the  presence  of  albumin  with  hyaline 
and  granular  casts.  The  blood  exam- 
ined after  death  showed  leucocytosis 
and  marked  pallor  of  certain  of  the 
erythrocytes.  The  autopsy  revealed 
fatty  and  parenchymatous  degeneration 
of  the  heart,  marked  hyperemia  and 
edema  of  the  viscera,  general  arterio- 
sclerosis, and  acute  nephritis. 

The  writer  believes  that  alcohol  taken 
with    or    before    the    administration    of 
coal-tar   antipyretics    favors   the    occur- 
rence  of    symptoms    of    poisoning,    and 
that    alcohol    is,    therefore,    contraindi- 
cated   in   all    cases    of   collapse    due   to 
these    drugs.     The    subjects    most    in- 
tolerant of  the  coal-tar  antipyretics  are 
those  that  normally  perspire  freely.     K. 
E.     Russow     (St.     Petersburger     med. 
Woch.,  Feb.  8,  1908). 
[The  remark  of  Russow  that  alcohol  tends 
to     aggravate     acetphenetidin     poisoning     is 
sustained    by    my    views.     While    the    latter 
tends  to  interfere  with  oxidation  by  diminish- 
ing the  volume   of  blood  admitted  into  the 
tissues,  alcohol  becomes  oxidized  at  the  ex- 
pense of  the  blood,  thus  increasing  the  tox- 
icity of  the  acetphenetidin.    C.  E.  de  M.  S.] 
A  girl  of  163^  years,  in  good  general 
health,  but  having  a  headache  and  feel- 
ing  that    she    had   taken    cold,    took    2 
headache     tablets     and     went     to     bed. 
About    an    hour    and    a   half   later   her 
lips  and  face  began  to  grow  blue,  and 
a  physician  was  sent  for.     Responding 
at   once,   he    found   the   girl   with   pro- 
nounced  cardiac   weakness    and   edema 
of     the     lungs.      Before     any     remedy 
could    be    administered    she    died.     The 
tablets    she    had    taken,    labeled    "Dan- 


bury's  headache  tablets,"  were  subse- 
quently found  on  examination  to  con- 
tain acetphenetidin.  G.  L.  Tobey  (Mo. 
Bull.,  State  Board  of  Health  of  Mass., 
Jan.,  1908). 

Of  70  cases  reported  by  41  observers 
in  the  literature  from  1887  to  1907,  3, 
or  4.2  per  cent.,  terminated  fatally. 
Sixty-three  of  the  70  cases  were  re- 
ported during  the  years  1887-90,  i.e.,  in 
the  period  just  following  the  advent  of 
acetphenetidin  as  a  medicinal  agent, 
when  the  drug  was  used  freely  in 
asthenic  as  well  as  sthenic  affections. 
The  most  prominent  ill  efifect  was  gen- 
eral systemic  depression,  which  was 
present  in  38.5  per  cent,  of  the  cases. 
In  17.1  per  cent.,  it  amounted  to  actual 
collapse.  Cyanosis  was  reported  in  34.3 
per  cent,  of  the  cases,  skin  affections 
of  various  kinds  in  30  per  cent.,  dyspnea 
in  14.3  per  cent.,  and  disturbances  of 
the  renal  function  in  10  per  cent. 
Kebler,  Morgan,  and  Rupp  (U.  S. 
Dept.  of  Agricul.,  Bureau  of  Chemistry, 
Bull.  No.  126,  July  3,  1909). 

Of  306  physicians  questioned  on  the 
subject  of  acetphenetidin  poisoning, 
66,  or  21.5  per  cent.,  stated  that  they  had 
observed  instances  of  poisoning  (as 
compared  with  76  per  cent,  of  288 
physicians  having  seen  instances  of 
acetanilide  poisoning).  These  66  ob- 
servers reported  95  cases  of  poisoning 
by  acetphenetidin,  including  7  deaths, 
i.e.,  7.3  per  cent.  The  character  of  the 
fatal  cases  and  the  doses  used  were  as 
follows : — 

Pneumonia,  70  grains  daily  for  two 
days ;   died  suddenly. 

Influenza,  5  grains  every  three  hours ; 
not  over  6  doses. 

Bronchitis  (1  year),  2  grains  every 
three  hours ;  5  doses ;  died  twelve 
hours  after  last  dose. 

Typhoid,  2^  grains  every  two  hours 
until  1  scruple  was  taken. 

Headache,  10  grains. 

Headache  (cerebral  tumor),  15  grains 
in  twelve  hours. 

Woman,  aged  76,  two  3-grain  doses 
two  hours  apart. 

Kebler,  Morgan,  and  Rupp  (U.  S. 
Dept.  of  Agricul.,  Bureau  of  Chemistry, 
Bull.  No.  126,  July  3,  1909). 


ACETPIIENETIDIN    (SAJOUS). 


249 


Treatment  of  Acute  Poisoning. — No 

special  reference  to  this  subject  having 
been  found  in  the  Hterature,  we  can  only 
recall  the  plan  of  treatment  used  for 
poisoning  by  the  other  coal-tar  deriva- 
tives, the  toxic  effects  of  which  are  iden- 
tical. Stimulants  to  the  circulation  and 
respiration,  such  as  strychnine,  atro- 
pine, aromatic  spirits  of  ammonia, 
ether  h}-podermically,  and  digitalis; 
saline  solution  by  enteroclysis  or  hy- 
podermoclysis,  etc.  The  application 
of  heat  to  the  body  should  never  be 
neglected  in  cases  of  collapse.  Arti- 
ficial respiration  is  always  valuable, 
and  inhalations  of  oxygen  may  be  re- 
sorted to  as  an  ultimate  measure. 

[Of  the  foregoing  the  only  drugs  that  I 
do  not  regard  as  harmful  in  cases  of  acet- 
phenetidin  poisoning  are,  in  the  order  given : 
the  aromatic  spirits  of  ammonia  and  the  salt 
solution,  which  jointly,  by  increasing  the 
alkalinity  and  osmotic  properties  and  fluidity 
of  the  blood,  tend  to  reduce  its  toxic  action 
on  the  sympathetic  center  and  relax  the  con- 
stricted arterioles ;  the  application  of  heat 
to  the  surface  and  inhalations  of  oxygen. 
Strychnine,  atropine,  ether,  and  digitalis  all 
tend  to  aggravate  the  trouble  by  increasing, 
if  anything,  the  constriction  of  the  arterioles. 

The  agents  indicated — only  from  my  view- 
point— are  those  which  cause  dilatation  of 
the  arterioler  by  depressing  the  sympathetic 
center :  amyl  nitrite  by  inhalation,  and  nitro- 
glycerin to  sustain  the  effect,  or  sweet 
spirits  of  niter,  the  latter  in  full  doses. 
C.  E.  DE  M.  S.] 

CHRONIC    POISONING.— While 

not  as  frequent  as  chronic  acetanilide 
poisoning,  chronic  acetphenetidin  poi- 
soning is  nonetheless  fairly  common. 
The  symptoms  show  a  great  similar- 
ity to  those  produced  by  the  habitual 
use  of  acetanilide,  consisting  chiefly 
of  nervous  and  digestive  disturbances, 
a  cyanotic  coloration  of  the  skin,  ane- 
mia, and  weakened  heart  action. 

Case     of     a     woman,     previously     "a 
healthy,  buxom  country  girl,"  who  had 


been  addicted  to  the  acetphenetidin  habit 
for  about  seven  months,  ingesting  from 
15  to  20  grains  daily.  The  habit  was 
found  out  by  her  husband  when  her 
supply  of  the  drug  gave  out  and  the 
local  pharmacist  also  ran  out  of  a  sup- 
ply temporarily.  Violent  convulsive 
and  hysterical  seizures  appeared,  and 
continued  until  acetphenetidin  had  been 
obtained  for  her.  The  pulse  rose  to 
170  and  became  feeble ;  respiration,  30, 
spasmodic ;  pupils  widely  dilated ;  pallor 
and  cold  perspiration.  The  patient  had 
over  a  dozen  convulsions  and  vomited 
freely.  Examination  subsequent  to  the 
attack  showed  some  anemia,  poor  com- 
plexion, weak  circulation,  pulse  124, 
sleep  restless  and  troubled,  digestion 
impaired,  occasional  vertigo.  J.  S. 
Davis  (Amer.  Med.  and  Surg.  Bull., 
July,   1894). 

Case  of  acute  dysentery  reported  in 
which  the  exhibition  of  approximately 
3000  grains  of  acetphenetidin  in  5-grain 
doses  within  sixty  days  for  fever  was 
followed  by,  marked  depression  and 
rapid  dilatation  of  the  heart  resulting 
in  death.  The  fatal  ending  could  fairly 
be  ascribed  to  chronic  poisoning  by  the 
drug.  A.  T.  White  (Jour,  of  Tropical 
Med.,  June,  1903). 

From  collective  reports  of  cases  it 
would  appear  that  toxic  manifestations 
are  somewhat  less  likely  to  develop 
when  acetphenetidin  is  taken  habitu- 
ally than  when  acetanilide  is  the  drug 
used. 

In  the  replies  of  400  physicians  to  a 
set  of  questions  sent  out  by  the  Bureau 
of  Chemistry  of  the  U.  S.  Department 
of  Agriculture,  112  instances  of  the 
acetanilide  habit  were  reported,  7  of 
the  antipyrin  habit,  and  17  of  the  acet- 
phenetidin habit.  The  number  of  cases 
in  which  ill  effects  were  observed  from 
the  use  of  acetanilide  was  85,  from 
antipyrin  2,  and  from  acetphenetidin 
7.  The  chief  symptoms  observed  from 
the  habitual  use  of  these  drugs  were: 
Nervous  depression,  44  cases ;  cyanosis, 
27;  cardiac  depression,  18,  anemia,  15; 
dyspnea  on  exertion,  8;  insomnia,  4; 
constipation,    3;     edema,    2;    increased 


250 


ACETPHENETIDIN    (SAJOUS). 


headache,  2;  icterus,  1;  muscular 
twitchings,  1 ;  loss  of  sexual  power,  1. 
In  S  of  the  cases  of  acetphenetidin 
habit  protracted  ill  effects  were  noted, 
as  compared  with  32  instances  in  case 
of  acetanilide  and  2  instances  in  case 
of  antipyrin.  The  chronic  symptoms 
oftenest  noted  were  anemia,  general 
debility,  nervousness,  and  weak  and 
irregular  heart  action.  Kebler,  Mor- 
gan, and  Rupp  (U.  S.  Dept  of  Agricul., 
Bureau  of  Chemistry,  Bull.  No.  126, 
July  3,  1909). 

Treatment  of  Chronic  Poisoning. — 

The  measures  required  upon  with- 
drawal of  the  drug  will  generally  com- 
prise the  use  of  stimulants,  saline  lax- 
atives, and  codeine, — the  latter  used 
with  caution  in  amounts  just  sufficient 
to  mitigate  pain  and  favor  sleep  {v. 
Treatment  of  Chronic  Acetanilide 
Poisoning). 

THERAPEUTICS.— As  Antipy- 
retic.— Acetphenetidin  is  generally  con- 
sidered the  safest  of  the  coal-tar  an- 
tipyretics. Its  effect  in  reducing  tem- 
perature is  marked ;  as  previously  stated, 
its  action  begins  in  about  thirty  minutes 
and  reaches  its  maximum  in  three  to 
four  hours.  According  to  Heusner,  1 
Gm.  (15  grains)  of  this  drug  is  the  equal 
in  antithermic  power  of  0.5  Gm.  (7^ 
grains)  of  acetanilide,  and  2  Gm.  (30 
grains)  of  antipyrin.  The  relative 
infrequency  with  which  it  causes  cya- 
nosis, depression,  and  other  unpleasant 
or  dangerous  effects  recommends  its 
general  use  as  an  antipyretic  in  prefer- 
ence to  the  older  coal-tar  remedies  if 
used  at  all.  The  employment  of  anti- 
pyretics other  than  hydrotherapy  and 
other  external  measures  is  decidedly  on 
the  wane,  however,  in  the  hands  of 
competent  clinicians. 

Exception  to  this  is  probably  only 
to  be  made  where  prompt  reduction 
of  fever  is  required,  as  in  cases  of  hy- 
perpyrexia;  here    acetanilide,    whether 


used  in  conjunction  with  hydrothera- 
peutic  measures  or  not,  may  prove  more 
effective  than  acetphenetidin.  It  is  be- 
lieved, however,  that  the  effect  of  the 
latter  drug  is  more  lasting  than  that  of 
acetanilide ;  the  greater  tendency  of 
which  to  depress  the  circulatory  and 
respiratory  organs  should  also  be  re- 
membered. As  stated  above,  however, 
the  use  of  antipyretics  in  the  various 
forms  of  fever  is  now  deemed  inadvis- 
able by  most  authorities.  Moreover, 
these  agents,  by  causing  the  temperature 
records  to  lose  their  characteristic  fea- 
tures, may  impair  their  value  for  diag- 
nostic and  prognostic  purposes.  The 
alleged  prejudicial  influence,  on  the 
other  hand,  that  chemical  antipyretics 
have  been  said  to  exert  on  the  sub- 
stances of  the  blood-serum  that  antag- 
onize disease  has  been  shown  not  to 
exist,  at  least  in  the  case  of  the  agglu- 
tinating bodies  of  typhoid  serum  (Soll- 
mann).  When  delirium  is  present  in 
fever,  the  mild  narcotic  action  exerted 
by  the  coal-tar  antipyretics,  and  in  par- 
ticular by  acetphenetidin,  may  prove 
advantageous. 

[The  cardinal  feature  still  overlooked  is 
that  fever  is  the  external  expression  of  the 
process  through  which  the  body  defends 
itself  against  infection.  When  hyperthermia 
is  present  (over  105.5°  F.),  however,  there  is 
good  ground  for  the  belief  that  the  immuniz- 
ing process  is  so  active  that  the  blood-cells 
and  tissues  may  also  be  digested  by  the 
defensive  blood  constituents  (hemolysis  and 
autolysis)  along  with  the  bacteria  and  their 
toxins.  It  is  then,  especially  in  such  diseases 
as  pleurisy,  endocarditis,  acute  rheumatism, 
which,  from  my  viewpoint,  are  mainly  due 
to  excessive  proteolytic  activity  of  the  blood, 
that  acetphenetidin  can  find  a  useful  applica- 
tion in  fever. 

It  should  be  remembered  that  the  surface 
temperature  is  often  the  expression  of  too 
slow  elimination  of  heat  from  the  superficial 
tissues,  where  the  febrile  process  is  very 
active,  and  that  cool  sponging  by  taking  up 


ACETPHENETIDIN    (SAJOUS). 


251 


this  accumulated  heat  lowers  the  temperature 
promptly  to  the  great  relief  of  the  patient. 
C.  E.  DE  M.   S.] 

As  an  Analgesic. — Phenacetin  is 
chielly  of  value  for  the  relief  of  pain, 
especially  of  pain  of  the  nenralgic  type. 
In  pains  due  to  gross  inllammations  or 
deep-seated  distress,  the  result  of  or- 
ganic disease  of  viscera,  morphine  is  far 
more  effective'  than  phenacetin.  But 
in  ]X'uns  due  to  nervous  disorders,  es- 
pecially neuralgia  and  neuritis,  and  in 
various  forms  of  headache,  acetpheneti- 
din  has  come  to  be  considered  almost 
as  a  specific.  In  hemicrania,  in  head- 
ache due  to  eye-strain  or  insufficiency 
of  certain  of  the  extraocular  muscles,  in 
intercostal  neuralgia,  sciatica,  gastral- 
gia,  and  in  the  pains  of  tabes  dorsalis, 
acetphenetidin  frequently  affords  con- 
siderable rehef. 

The  manner  in  which  this  drug,  in 
common  with  other  coal-tar  antipyret- 
ics, acts  in  relieving  headache  has  not 
yet  been  definitely  ascertained.  Accord- 
ing to  Brunton,  headache  is  associated 
with  and  caused  by  what  he  terms  a 
"colic"  of  the  arteries  of  the  head,  the 
peripheral  vessels  being  contracted  and 
the  central  vessels  dilated;  the  drug 
would  presumably  give  relief  by  over- 
coming this  abnormal  condition  of  the 
cephalic  arteries.  E.  Weber  has  re- 
cently demonstrated  experimentally 
in  dogs  whose  brain  had  been  exposed 
that  coal-tar  drugs  cause  constriction 
of  the  vessels  on  the  surface  of  the 
cerebrum. 

It  is  well  known,  moreover,  that 
caffeine,  an  undoubted  vasoconstrictor, 
when  combined  with  the  coal-tar  drugs, 
greatly  assists  their  analgesic  action  in 
headaches.  Hence  it  would  seem  as  if 
the  relief  given  in  these  cases  were  due, 
in  some  way,  to  a  modification  in  the 
caliber  of  the  vessels. 


[Weber's  experiments  (Arch.  f.  Physiol., 
p.  348,  1909)  confirmed  the  conception  of 
action  of  coal-tar  antipyretics  wh'ch  I  had 
advanced  in  1907  in  '"Internal  Secretions,"' 
etc.,  vol.  ii,  pp.  1282  to  1299,  in  which  I 
showed  that  the  reduction  of  pain  was  du2 
to  constriction  of  the  arterioles  and  the  re- 
sulting diminution  of  arterial  blood  admitted 
to  the  sensory  terminals.     C.  E.  de  M.  S.] 

In  acute  rheumatism,  acetpheneti- 
din has  been  found  useful  as  an  anal- 
gesic in  doses  of  3  to  8  grains  (0.2  to 
0.5  gram),  given  every  four  hours.  A 
valuable  combination  is  4  grains  each  of 
acetphenetidin  and  salol,  given  three  or 
four  times  daily.  Eldredge  counsels  the 
administration  of  acetphenetidin  in  pow- 
der and  salicylic  acid  in  solution,  the 
dose  of  each  being  regulated  according 
to  the  patient's  susceptibility  and  the 
severity  of  the  attack.  In  cases  with 
cardiac  complications,  he  claims  not  to 
have  observed  any  depressing  action  on 
the  heart  when  the  drug  was  given  to 
reduce  fever.  Hirschfelder  noted  spe- 
cially the  fact  that  sometimes  a  hyp- 
notic action  seemed  to  be  produced.  In 
subacute  rheumatism  and  in  lumbago 
and  other  rheumatic  muscular  pains, 
the  drug  is  also  frequently  effective. 

In  gonorrheal  rheumatism,  acetphe- 
netidin was  found  by  Eldredge  to  act 
well  when  given  with  potassium  iodide 
and  sodium  salicylate. 

In  influenza,  acetphenetidin  has  be- 
come a  favorite  remedy.  The  pains  in 
the  head,  back,  and  limbs  are  relieved, 
and  the  fever  reduced.  The  drug  may 
be  given  alone  in  powder  form,  or  com- 
bined with  other  remedies,  e.g.,  quinine. 
In  this  disease,  essentially  an  asthenic 
disorder,  it  is  important  that  the  anal- 
gesia be  secured  with  the  least  possible 
degree  of  general  depression;  hence 
acetphenetidin  should  always  be  given 
the  preference  over  its  more  depressing 
congeners — acetanilide  and  antipyrin. 


252 


ACETYLENE. 


In  whooping-cough,  acetphenetidin 
diminishes  the  severity  and  frequency 
of  the  paroxysms.  In  children,  1  or  2 
grains  (0.06  to  0.013  gram),  given  three 
or  four  times  daih^  are  generally  suf- 
ficient. 

Chorea  has  also  been  treated  with 
acetphenetidin.  Like  the  other  coal- 
tar  drugs,  acetphenetidin  exerts  a  not 
inconsiderable  effect  on  the  motor  func- 
tions and  reflex  action,  as  well  as  on 
general  sensibility.  Hence  the  fact  that 
it  sometimes  proves  useful  in  this  dis- 
order. 

Insomnia,  the  result  of  overwork  or 
general  nervous  excitability,  may  yield 
to  acetphenetidin.  Kiernan  reported 
having  seen  it  bring  on  sleep  in  persons 
suft'ering  from  insomnia  due  to  simple 
exhaustion.  In  view  of  the  possible 
serious  depressive  effects  from  an  over- 
dose, the  likelihood  of  a  drug  habit  be- 
ing formed,  and  the  fact  that  much 
safer  and  better  hypnotics  are  available, 
it  seems  doubtful  whether  the  use  of 
acetphenetidin  for  this  purpose  should 
be  encouraged. 

The  same  is  probably  true  of  the  use 
of  acetphenetidin  in  the  initial  stage  of 
pneumonia,  in  which  it  has  been  em- 
ployed to  relieve  distress,  bring  on 
sweating,  reduce  fever,  and  favor  sleep. 
If  the  drug  is  used  at  all,  it  must  surely 
be  withdrawn  as  soon  as  the  patient 
begins  to  show  pronounced  general  de- 
pression and  signs  of  lowered  circula- 
tory activity.  In  pleurisy  acetpheneti- 
din has  likewise  been  used  to  relieve 
the  pain  of  the  initial  stage. 

The  first  stage  of  acute  coryza  may 
be  shortened  by  giving  a  few  doses  of 
acetphenetidin,  which  will  not  only  pro- 
mote sweating  and  lower  the  tempera- 
ture, but  also  relieve  the  unpleasant 
accompanying  sensations.  A  powder 
containing  5  grains  (0.3  gram)  each  of 


acetphenetidin  and  salol,  together  with 
1  grain  (0.06  gram)  of  citrated  caffeine, 
may  be  administered  every  three  hours 
for  3  doses  with  advantage. 

In  diabetes  mellitus  acetphenetidin, 
in  common  with  other  coal-tar  drugs, 
has  been  prescribed,  generally  with  but 
temporary  benefit. 

Local  Uses. — Acetphenetidin  is 
sometimes  used  externally  for  its  anal- 
gesic and  antiseptic  properties.  Dusted 
in  finely  powdered  form  on  the  raw  sur- 
faces of  ulcerations  of  various  kinds,  it 
not  only  relieves  pain,  but  favors  the 
development  of  healthy  granulations, 
thereby  hastening  the  healing  process. 
Because  of  its  low  degree  of  solubility 
in  water,  as  compared  with  antipyrin 
and  acetanilide,  the  likelihood  of  the 
absorption  of  a  toxic  amount  of  acet- 
phenetidin from  open  surfaces  is 
somewhat  less  than  wdth  the  above- 
mentioned  agents.  Nevertheless,  this 
danger  should  always  be  kept  in 
mind,  and  the  external  use  of  the  drug 
confined  to  lesions  covering  a  small 
area  only. 

C.  E.  DE  M.  Sajous 

AND 

L.  T.  DE  M.  Sajous, 

Philadelphia. 

ACETYLENE.— When  calcium  car- 
bide (CaC2)  is  brought  in  contact  with 
water,  acetylene  gas  is  formed.  Being 
capable,  when  ignited,  of  furnishing  a  de- 
gree of  light  far  superior  to  that  of  ordi- 
nary gas,  acetylene  has  in  recent  years 
been  considerably  used  as  an  illuminant. 
When  prepared  from  pure  calcium  carbide 
and  purified  by  liquefaction,  it  has  a  pleas- 
ant ethereal  odor  and  can  be  breathed  in 
small  quantities  without  giving  rise  to  ill 
effects.  Impure  gas,  prepared  from  coal 
or  impure  lime,  may  contain  calcium  sul- 
phide and  phosphide,  and  the  acetylene 
prepared  from  it  may  then  have  a  very 
unpleasant  odor. 

Acetylene  Poisoning. — Acetylene  may  be 
fatally  poisonous  when  present  in  proper- 


ACIDITY    OF    THE    GASTRIC    CONTENTS. 


253 


tions  as  high  as  40  per  cent,  by  volunio,  as 
shown  by  Grehant,  Berthelot,  and  Mois- 
sant.  A  mixture  of  20  volumes  of  acety- 
lene— prepared  from  calcium  carbide,  20.8 
volumes  of  oxygen,  and  59.2  volumes  of 
nitrogen — was  breathed  by  a  dog  for 
thirty-five  minutes  without  any  marked 
disturbance,  and  100  c.c.  of  the  blood  were 
found  to  contain  10  c.c.  of  acetylene.  With 
40  volumes  of  acetylene,  the  proportion  of 
oxygen  remaining  the  same,  a  dog  died  in 
less  than  an  hour,  owing  to  failure  of  the 
heart's  action,  and  100  c.c.  of  blood  con- 
tained 20  c.c.  of  acetylene.  With  79  vol- 
umes of  acetylene  and  21  volumes  of  oxy- 
gen the  poisonous  efifects  were  still  more 
strongly  marked. 

The  poisonous  action  of  acetylene  itself 
is  feeble  when  the  blood  is  at  the  same 
time  supplied  from  the  air  with  the  usual 
amount  of  oxygen.  In  other  words,  acety- 
lene inhaled  in  the  open  air  is  but  slightly 
harmful.  Brociner  found  that  100  volumes 
of  blood  dissolve  about  80  volumes  of 
acetj^lene;  the  solution  shows  no  charac- 
teristic spectrum,  and  is  reduced  by  am- 
monium sulphide  as  readily  as  ordinary 
arterial  blood.  If  any  compound  of  acety- 
lene and  hemoglobin  is  formed,  it  is  very 
Unstable,  and  is  not  analogous  to  carboxy- 
hemoglobin. 

In  a  closed  room,  however,  where  the 
oxygen  is  not  kept  up  to  the  normal  stand- 
ard, when  the  accumulation  of  a  foreign 
'gas  would  prevent  the  constant  renewal  of 
air  through  window  and  door  interstices  or 
open  chimneys,  and  where  the  products 
of  respiration  would  be  allowed  to  accu- 
mulate, it  would  quickly  prove  mortal 
by  paralyzing  the  respiratory  function. 
Mosso  and  Ottolenghi  found  experimen- 
tally that  acetylene  has  considerable  toxic 
power.  One  pint  of  the  pure  gas  caused 
severe  sj^mptoms  of  poisoning  in  dogs,  and 
even  when  mixed  with  air  (20  per  cent.) 
it  proved  fatal  after  an  hour.  If  the  gas 
was  administered  rapidly,  the  animal  re- 
covered when  placed  in  the  open  air,  but 
if  given  slowly  this  did  not  occur,  and  the 
animals  died. 

Thomas  Oliver  has  shown  that  a  mixture 
of  air  and  acetylene  commences  to  be  ex- 
plosive when  it  contains  5  per  cent,  of 
acetylene,  whereas  it  requires  the  presence 
of  8  per  cent,  of  coal  gas  to  make  a  similar 


mi.xturc  cxplosable.  If  a  rabbit  is  placed 
in  a  bell-jar  into  which  ordinary  air  and 
acetylene  are  pumped,  the  animal  seems 
for  a  long  period  to  experience  very  little 
inconvenience.  It  is  not  until  ordinary 
atmospheric  air  is  excluded  and  only  acety- 
lene admitted  that  symptoms  gradually 
and  slowly  develop.  After  a  more  length- 
ened exposure  to  acetylene  than  that 
which  is  necessary  for  coal  gas  the  animal 
becomes  intoxicated,  it  falls  over  on  its 
side  apparently  profoundly  asleep,  and, 
while  all  through  the  experiment  its 
breathing  has  been  somewhat  short  and 
rapid,  stupor  steals  over  the  animal  ap- 
parently painlessly.  A  few  inhalations  of 
atmospheric  air  are  sufficient  to  restore  to 
the  animal  all  its  faculties.  Should  in- 
halation have  been  pushed  further  and  the 
animal  have  been  very  deeply  asphyxiated, 
death  may  ensue,  cyanosis,  hitherto  ob- 
served, being  rapidly  replaced  by  extreme 
pallor. 

Treatment  of  Acetylene  Poisoning. — 
That  fresh  air  should  at  once  be  given  the 
patient  need  hardly  be  mentioned.  The 
patient  should  be  removed  from  the 
poisoned  atmosphere  into  a  well-ventilated 
room  and  artificial  respiration  practised. 
Hypodermic  injections  of  strychnine  and 
digitalis  should  be  administered  while 
oxygen  is  sent  for.  This  gas  should  be 
inhaled  as  soon  as  practicable,  while  arti- 
ficial respiration  is  continued  with  vigor, 
the  patient  being  simultaneously  rubbed. 
Rectal  injections  of  warm  coffee  are  also 
useful.  Hypodermoclysis,  with  epinephrin 
or  adrenalin  1  :  1000  solution  introduced 
drop  by  drop  into  the  saline  solution  by 
pushing  the  hypodermic  needle  into  the 
rubber  pipe,  is  indicated  in  all  cases  of 
severe  poisoning  by  the  gas. 

In  all  such  cases  the  efforts  of  the  physi- 
cian should  be  kept  up  a  long  time,  the 
respiration  and  pulse  being  unreliable 
guides  as  regards  the  presence  in  the  sys- 
tem of  sufficient  life  to  render  resuscitation 
possible.  S. 

ACIDITY  OF  THE  GASTRIC 
CONTENTS,  TESTS  FOR.— While 

the  acidity  of  normal  gastric  juice  is  due 
mainly  to  the  presence  of  hydrochloric  acid, 
.  departures  from  the  normal  proportion  of 
this  acid   in  the  gastric  contents  have  been 


254 


ACIDITY    OF    THE    GASTRIC    CONTENTS. 


found  to  accompany  with  sufficient  frequency 
certain  disorders  to  facilitate  the  recognition 
of  these  disorders.  Thus,  a  proportion  of 
hydrochloric  acid  of  0.15  to  0.3  per  cent, 
represents  the  acidity  found  under  normal 
conditions,  i.e.,  euchlorhydria,  but  an  ex- 
cess of  acid,  hyperchlorhydria,  is  common 
in  gastric  ulcer,  gastroptosis,  hysteria, 
tabes,  and  other  disorders.  Hypochlor- 
hydria,  a  deficiency  of  hydrochloric  acid, 
also  accompanies  various  disorders,  espe- 
cially gastric  cancer,  neurasthenia,  anemia, 
chronic  gastritis  of  long  duration,  gastric 
neuroses,  and  certain  diseases  of  the  pan- 
creas, while  achlorhydria,  absence  of  hydro- 
chloric acid,  is  found  in  advanced  cases  of 
the  same  disorders.  Again,  the  fact  that 
hydrochloric  acid  is  necessary  to  peptic 
digestion,  while  acting  'cs  a  powerful  anti- 
septic to  the  ingested  foodstuffs,  further 
indicates  the  practical  importance  of  ascer- 
taining accurately  the  acidit}^  of  the  gastric 
contents. 

To  obtain  accurate  information,  it  is 
necessary  to  administer  a  test-meal  con- 
taining a  definite  quantity  of  foodstuffs, 
and  to  leave  the  latter  in  the  stomach  a 
definite  time. 

Test-meals. — Those  described  are  gen- 
erally given  preference: — 

The  Ewald-Boas  breakfast  consists  of  1 
roll  weighing  about  35  Gm.  (9  drams)  and 
a  large  wineglass  of  300  Gm.  (10  ounces) 
of  water.  This  meal  should  be  taken  early 
in  the  morning  on  an  empty  stomach,  the 
bread  being  eaten  slowly  and  the  water 
sipped  while  this  is  done.  At  the  end  of 
one  hour,  20  to  60  c.c.  (5  to  10  drams)  of 
the  meal  should  be  withdrawn  from  the 
stomach  in  the  manner  indicated  below. 

The  Leube-Riegel  test-meal  consists  of 
beef  soup,  400  c.c.  (12  ounces);  beefsteak 
finely  chopped,  200  Gm.  (6  ounces) ;  wheat 
bread  or  potato,  50  Gm.  (1.6  ounces),  and 
water,  200  Gm.  (6  ounces).  The  gastric 
contents  should  be  removed  at  the  end  of 
four  hours. 

The  Salzer  inetJiod  inckides  two  meals: 
The  first  consists  of  30  Gm.  (1  ounce)  of 
lean  roast  beef  chopped  very  fine ;  milk, 
250  c.c.  (8  ounces);  rice,  50  Gm.,  and  1 
soft-boiled  egg.  The  second  meal,  given 
four  hours  later,  is  an  Ewald-Boas  break- 
fast, described  above.  At  the  end  of  five 
hours  after  the  first  meal,  that  is  to  say. 


one  hour  after  the  second,  the  gastric  con- , 
tents  is  withdrawn. 

The  Salzer  test  affords,  in  addition  to  the 
opportunity  of  ascertaining  acidity,  that 
of  determining  the  motility  of  the  gastric 
muscles;  for  if  particles  of  meat  of  the 
first  meal  are  still  present  at  the  end  of 
five  hours,  the  propulsive  activity  of  the 
stomach  wall  is  deficient. 

Withdrawal  of  Gastric  Contents. — This, 
the  next  step  of  the  examination,  is  car- 
ried out  with  the  aid  of  a  flexible  red  rub- 
ber tube  about  a  yard  in  length,  the 
catheter-like  end  of  which  is  provided,  a 
short  distance  above  the  tip,  with  a  fenes- 
tra or  opening.  It  is  an  ordinary  stomach 
tube  the  upper  end  of  which  is  funnel- 
shaped.  About  2  feet  above  this  end  is  a 
mark  which,  when  the  tube  is  introduced 
sufficiently  far,  i.e.,  when  its  tip  reaches 
the  bottom  of  the  stomach,  corresponds 
with  the  incisor  teeth  of  an  adult. 

The  patient's  clothing  being  protected 
with  a  towel  tied  round  his  or  her  neck, 
the  tube,  previously  warmed  by  being 
placed  in  a  bowl  of  warm  wat  r  and  lubri- 
cated with  glycerin,  is  introduced,  i.e., 
passed  down  the  esophagus.  This  is  done 
readily  by  pushing  the  end  of  the  tube 
gently  into  the  latter,  over  the  epiglottis, 
while  the  patient  swallows,  and  as  often 
as  he  does  so.  In  some  cases,  especially 
the  first  time,  the  procedure  may  cause 
gagging,  but  this  can  be  avoided  by  pass- 
ing the  tube  on  one  side  of  the  epiglottis, 
i.e.,  in  either  pyriform  sinus.  The  sensi- 
tive surface  of  the  pharynx  is  thus  avoidea. 

To  withdraw  the  gastric  contents  several 
ways  are  available.  The  easiest  is  to  de- 
press the  external  end  of  the  tube  as  soon 
as  the  latter  is  in  situ,  and  request  the  pa- 
tient to  lean  forward  and  cough  a  few 
times  or  contract  his  abdominal  muscles. 
An  essential  point,  however,  is  that  the 
(clean)  bowl  in  which  the  gastric  contents 
is  to  be  collected  must  be  considerably 
below  the  level  of  the  patient's  stomach, 
i.e.,  between  his  knees,  so  as  to  obtain  the 
benefit  of  siphonage.  The  expulsion  of 
the  gastric  contents  is  facilitated  by  press- 
ing on  the  stomach  while  the  patient  is 
coughing  or  contracting  his  abdominal 
m.uscles;  it  is  further  aided  by  having  him 
lie  down  on  a  lounge,  the  bowl  being 
placed  on  the  floor.    It  is  not  necessary  to 


ACIDITY    OF   THE    GASTRIC    CONTENTS. 


-)■■ 


empty  the  stomach,  a  couple  of  table- 
spoonfuls  (about  30  c.c.)  suflicing  fur  all 
purposes. 

Various  pumps,  aspirating  bulbs,  etc., 
have  been  invented  to  deplete  the  stomach, 
but  the}'-  entail  the  use  of  parts  that  arc 
difficult  to  clean  properly,  and  expose  the 
gastric  mucosa  to  the  evil  effects  of  direct 
suction  by  the  tube.  Moreover,  compli- 
cated instnmients  tend  to  increase  the 
timidity  of  the  patient,  which,  at  best,  is 
sometimes  difficult  to  overcome.  Briefly, 
the  above-described  "simple  expression 
method''  is,  on  the  whole,  the  most  satis- 
f  act  or}'. 

Contraindications  to  the  Use  of  the 
Stomach  Tube.^ — In  a  certain  proportion  of 
cases,  however,  even  the  use  of  the  simple 
stomach  tube  may  prove  dangerous.  They 
are:  cases  of  advanced  cardiac  disorder; 
advanced  arteriosclerosis,  especially  if 
there  is  a  history  of  cerebral  hemorrhage 
or  "slight  stroke";  elderly  persons  of 
apoplectic  build.  In  either  of  these  the 
tube  ma}''  cause  a  sudden  reflex  rise  of  the 
blood-pressure  and  rupture  of  any  diseased 
vascular  tissue.  A  history  of  recent  hema- 
temesis  or  of  bloody  or  tarry  stools  is 
also  a  contraindication,  since  the  bleeding 
may  be  due  to  gastric  ulcer  or  cancer, 
which  the  extremity  of  the  tube  might 
readily  abrade,  and  thus  cause  renewal  of 
the  hemorrhages.  Advanced  tuberculosis, 
marked  emphysema,  pregnancy,  and  ex- 
treme debility  are  also  recognized  as  con- 
traindications. 

Determination  of  Free  Acids. — The  mere 
presence  of  any  free  acid,  hydrochloric, 
lactic,  etc.,  can  readily  be  determined  by 
using  paper  previously  dipped  in  a  solu- 
tion of  Congo  red  and  dried.  This  turns 
blue  in  the  presence  of  free  acids,  but  does 
not  identify  one   acid  from  another. 

To  identify  hydrochloric  acid,  the  best 
reagent  is  probably  the  diniethylamidoaso- 
bencol.  It  may  be  used  in  0.5  per  cent, 
solution  or  in  absorbent  paper  allowed  to 
dry  before  using.  The  yellow  color  of 
either  becomes  reddish  pink  in  the  pres- 
ence of  hydrochloric  acid.  This  test  fur- 
nishes an  inkling  as  to  the  degree  of 
acidity  due  to  the  latter,  for  the  reddish- 
pink  color  becomes  much  deeper  in  pro- 
portion as  the  percentage  of  acid  is  great. 

Tropeolln  is  another  good  reagent  which 


can  be  used  in  the  same  manner.  Its  yel- 
lowish-brown alcoholic  solution  turns  red 
in  the  presence  of  both  hydrochloric  acid 
and  lactic  acid;  but  the  former  can  be 
differentiated  l)y  spreading  a  few  drops  of 
a  saturated  solution  in  a  porcelain  dish, 
and  adding  thereto  an  equal  quantity  of 
the  gastric  fluid.  On  mixing  them  and 
heating  them  gent'y,  blue  and  lilac  stripes 
(formed  by  hydrochloric  acid  only)  appear. 
An  extremely  delicate  test,  which  will 
detect  1  part  of  hydrochloric  acid  in 
20,000  parts  of  water,  is  Guiisburg's,  whose 
reagent   consists    of: — 

IJ  Phloroghic'm    2  Gm.  (30  gr.) . 

I'aniUin  1  Gm.  (15  gr.). 

Absolute  alcohol 30  c.c.  (1  oz.). 

It  should  be  kept  in  a  dark  bottle.  By 
adding  a  few  drops  of  this  reagent  to  the 
gastric  filtrate  and  allowing  the  mixture 
to  evaporate  to  dryness,  a  beautiful  rose- 
red  tinge  is  obtained  if  free  hydrochloric 
acid  is  present. 

To  Ascertain  the  Total  Acidity. — The 
easiest  method  is  to  add  1  drop  of  a  1  per 
cent,  solution  of  phenolphtlialeiii  to  10  c.c. 
(2^  drams)  of  the  gastric  fluid,  after 
filtering  the  latter,  and  neutralizing  the 
mixture  by  a  given  quantity  of  decinormal 
solution  (about  30  grains  to  the  pint — 2 
Gm.  in  500  c.c.  of  distilled  water)  of 
sodium  hydroxide.  The  technique  of  the 
procedure  is  as  follows:  Place  10  c.c.  of 
the  filtered  gastric  fluid  in  a  beaker,  and 
add  thereto  2  drops  of  phenolphthalein 
solution.  Then  add  the  decinormal  sodium 
hydroxide  solution  from  a  graduated  bu- 
rette (mixing  with  a  glass  rod)  until  a 
permanent  red  or  reddish-pink  color  ap- 
pears, which  means  complete  neutraliza- 
tion. Now,  the  number  of  c.c.  (say  4  or 
4.5)  of  sodium  hydrate  solution  necessary 
to  obtain  the  latter,  as  shown  by  the 
graduated  burette,  with  a  naught  to  the 
right  of  this  figure  (making  40.0  or  45.0  of 
the  above  figures),  will  represent  the  per- 
centage of  total  acidity. 

A  watery  solution  of  Congo  red  may  be 
used  instead  of  phenolphthalein.  As  we 
have  seen,  free  hydrochloric  acid  in  the 
gastric  fluid  or  chyme  changes  the  red 
color  to  blue.  If,  now,  decinormal  sodium 
hydrate  solution  (vide  supra)  is  slowly 
added  to  the  mixture  until  the  Congo  red 


256 


ACNE    (STELWAGON). 


is  restored,  the  number  of  cubic  centi- 
meters of  the  sodium  hydrate  solution  re- 
quired to  obtain  this  result  will  represent 
the  amount  of  free  hydrochloric  acid. 

Lactic  acid,  which  suggests  the  presence 
of  cancer  or  dilatation,  being  contained  in 
all  bakery  products,  in  meats  as  sarco- 
lactic  acid,  sour  milk,  sauerkraut,  and 
sour  gherkins,  a  special  meal  is  necessary 
to  eliminate  from  the  test  the  acid  due  to 


Strauss's  separating  funnel  for  lactic  acid  test. 

foods.  A  bowl  of  soup  prepared  with 
Knorr's  oatmeal,  rendered  palatable  by 
adding  common  salt,  suffices  for  this  pur- 
pose. Uffehnann's  reagent  may  then  be 
used.     It  is  composed  as  follows: — 

^  Solution   of  carbolic  acid    (4 

per  cent.)    10  c.c. 

Distilled  zvater 20  c.c. 

Official  neutral  ferric  chloride 
solution   1  drop. 

This  should  be  prepared  fresh  for  each 
test.  Its  amethyst-blue  color  will  be 
turned  to  canary  yellow  when  added  to 
the  gastric  filtrate. 


A  quantitative  estimation  of  lactic  acid 
may  be  obtained  by  Strauss's  method.  "A 
separating  funnel  (shown  in  the  annexed 
cut)  with  marks  at  S  c.c.  and  25  c.c.  is 
filled  to  the  first  mark  with  gastric  juice 
and  then  to  the  second  with  ether.  After 
thoroughly  shaking,  the  fluid  is  allowed  to 
?iow  out  to  the  first  mark  (5  c.c),  then 
filled  with  water  to  the  second  mark 
(25  c.c).  Two  drops  of  a  10  per  cent, 
solution  of  iron  chloride  are  then  added. 
A  beautiful  green  color  appears  in  the 
presence  of  amounts  exceeding  0.5  per 
mille."      (Lenhartz-Brooks.) 

Butyric  acid  and  other  fatty  acids,  on 
boiling  the  gastric  filtrate,  emit  a  charac- 
teristic odor.  They  also  turn  yellowish 
brown  in  the  presence  of  Uffehnann's  solu- 
tion, just  described.  Another  test  is  to 
shake  the  gastric  product  (unfiltered)  with 
acid-free  ether,  and  then  allow  the  latter 
to  evaporate.  On  adding  calcium  chloride 
to  a  watery  solution  of  the  residue,  the 
butyric  acid  forms  oil  droplets  with  the 
characteristic  odor  of  the  acid. 

Acetic  acid  also  emits  a  characteristic 
odor,  that  of  vinegar.  A  small  quantity  of 
gastric  filtrate,  say  10  c.c,  is  treated  with 
ether  as  above.  The  residue  being  dis- 
solved in  a  little  water  and  neutralized 
with  a  solution  of  sodium  carbonate,  a 
couple  of  drops  of  a  very  dilute  solution 
of  ferric  chloride  are  added.  The  filtrate 
then  becomes  dark  red  if  acetic  acid  is 
present.  Or  a  few  drops  of  sulphuric  acid 
and  alcohol  may  be  added  to  the  same 
neutralized  residue;  on  heating,  the  latter 
then  gives  off  the  characteristic  vinegar- 
like odor  of  acetic  acid.  S. 


ACIDOSIS. 

TION. 


See  AuTOiNTOxicA- 


ACNE.— DEFINITION.— Acne 

is  characterized  by  the  presence, 
usually  on  the  face,  of  small  elevations 
or  nodosities  varying"  in  size  from  a 
pinhead  to  a  pea.  These  elevations, 
or  pimples,  are  also  present  on  the 
back,  shoulders,  and  chest  in  many 
cases. 

SYMPTOMS.— The  elevations  are 
conical   or   hemispherical,   and,   as   a 


ACNE    (STELWAGON). 


257 


rule,  in  the  earliest  stage  of  the  lesion 
somewhat  painful,  espeeially  upon 
pressure.  In  most  of  the  lesions  there 
is  a  distinct  tendency  to  sui^purative 
change.  In  the  center  of  the  lesion  a 
whitish-}- ellow  spot  forms  where  the 
pus  raises  the  epidermis.  In  from 
three  to  ten  days,  or  even  longer,  the 
lesion  breaks  and  a  small  amount  of 
pus  is  discharged.  At  other  times  the 
pus  dries  to  a  thin  crust,  or  occasion- 
ally the  contents,  especially  in  slug- 
gish lesions,  are  absorbed.  A  red 
elevation  is  left  which  gradually  flat- 
tens out,  leaving  a  brownish  stain, 
which  eventually  disappears.  The 
surrounding  skin  is  frequently  oily 
and  shiny.  Small,  sluggish,  abscess- 
like lesions,  and  tumors  as  large  as  a 
pea  or  a  small  nut,  formed  by  reten- 
tion cysts  of  sebaceous  glands,  are 
sometimes  seen ;  they  may  gradually 
work  to  the  surface  or  may  persist  for 
months  and  finally  disappear  or  form 
hard  spherical  indurations  by  retrac- 
tion and  inspissation  of  their  contents. 
Scarring,  usually  consisting  of  small, 
white,  cicatricial  depressions,  is  to  be 
seen  as  a  consequence  in  some  cases. 
In  the  majority  of  cases,  however, 
permanent  marks  are  not  left.  The 
.regions  most  afifected  in  acne  are  the 
face,  shoulders,  and  anterior  and  pos- 
terior aspects  of  the  shoulders.  Occa- 
sional cases  are  observed  in  which  the 
back,  extending  as  far  down  as  the 
sacrum,  is  the  chief  seat  of  the  disease. 
In  rare  instances  (acne  cachecticorum, 
acne  scrofulosorum,  and  acne  medi- 
camentosa) the  eruption  may  be  more 
or  less  general. 

VARIETIES.— There  are  several 
varieties  of  lesion  observed  in  acne, 
one  kind  of  wdiich  is  apt  to  predomi- 
nate, and  this  has  given  rise  to  the  so- 
called  varieties  of  the  disease. 


1— : 


.Icnc  vulgaris,  or  acne  simplex,  is,  by 
far,  the  most  common  clinical  type. 
Tlie  lesions  are  usually  of  a  mixed 
character,  consi^^ting  of  blackheads, 
])inhead-  to  pea-sized  papules,  papulo- 
pustules, and  pustules.  Each  lesion 
may  in  its  beginning  have  a  small,  red 
areola.  There  is  also  slight  pain  upon 
pressure.  The  lesions  are  rapid  in 
evolution,  running  a  course  in  several 
days  to  a  week.  As  in  all  types,  they 
are  discrete  and  isolated. 

The  term  "acne  papulosa"  is  given  to 
a  not  uncommon  type  in  which  the 
lesions  are  usually  small  and  show  but 
little  disposition  to  reach  the  pustular 
stage,  disappearing  by  absorption  or 
by  desiccation  and  exfoliation. 

Acne  punctata  might  be  termed  mi- 
nute papular,  the  lesions  being,  for  the 
most,  pinhead  in  size,  with  a  central 
comedo,  or  blackhead. 

Acne  pustulosa  is  another  type  in 
which  the  lesions  go  rapidly  into  the 
pustular  stage,  the  eruption  appearing, 
for  the  most  part,  to  be  made  up, 
almost  entirely,  of  pustules.  In  size 
they  vary  from  a  large  pinhead  to  a 
large-sized  pea. 

Acne  indurata,  or  "tuberculosa,"  is  a 
form  of  the  eruption  in  which  the 
lesions  tend  to  be  closely  crowded 
here  and  there  and  in  such  places,  and 
also  with  single  lesions,  the  underly- 
ing base  becomes  hard,  inflamed,  and 
indurated,  being  also  somewhat  deep- 
seated. 

In  acne  phlegnionosa  the  inflamma- 
tory and  suppurative  process  begins 
deep  down  in  the  sebaceous  gland, 
forming  veritable  small  dermic  and 
intradermic  abscesses,  usually  with 
but  slight  tendency  to  break  through 
the  surface.  ■ 

Acne  cachecticorum  characterizes  an 
acneic  eruption,  more  or  less  general, 

■17 


258 


ACNE    (STELWAGON). 


occurring  in  weak,  cachectic  individ- 
uals; the  lesions  are  livid,  indolent, 
violet-red  papulopustules  of  moderate 
and  large  size  and  of  slow  evolution, 
leaving,  as  a  rule^  small  cicatrices. 
Acne  scrofulosorum  is  really  a  variety 
of  the  last  named, — acne  cachecti- 
corum, — occurring  in  those  of  dis- 
tinctly strumous  or  tuberculous  tem- 
perament. 

Acne  artificialis  sen  medicamentosa  is 
a  form  of  acneic  eruption  produced  by 
the  ingestion  of  certain  drugs,  as  the 
iodides  and  bromides,  and  also  by  the 
external  applications  of  certain  reme- 
dies, such  as  tar,  the  paraffin  oils,  etc. 

"Acne  atrophica"  is  a  name  given  to 
those  cases  of  acneic  eruption  which 
tend  to  leaA'e  depressed  scars.  This 
pxobably  occurs  most  frequently  in 
those  cases  in  which  the  lesions  are 
sluggishly  papular  or  papulopustular, 
the  lesions  disappearing  by  absorption 
or  crusting  and  leaving  behind  small, 
punched-out  cicatrices. 

Acne  hypertrophica  is  really  the  op- 
posite of  the  last-named  variety,  and 
occurs  in  about  the  same  kind  of 
cases,  small,  whitish,  connective-tissue, 
pinpoint  or  small-pea  sized  projecting 
hypertrophies  marking  the  sites  of  the 
lesions.     It  is  rare. 

ETIOLOGY.— Acne  begins  usually 
near  puberty,  when  the  pilar  system  is 
more  actively  developing,  and  the 
functions  of  the  sebaceous  glands  like- 
wise ;  and  is  more  frequent  among 
patients  with  digestive  troubles,  con- 
stipation, dilatation  of  the  stomach, 
menstrual  irregularities,  the  strumous 
diathesis,  possibly  the  arthritic  di- 
athesis, and  disturbances  of  the  nervous 
system. 

Acne  at  about  the  time  of  puberty 
may  be  of  intestinal  origin,  and  in  94.9 
per   cent,    of    a   series   of   33    cases   of 


acne  occurring  at  this  age  the  writer 
found  clear  evidence  of  abnormal  putre- 
factive changes  in  the  intestine,  as 
shown  by  the  presence  of  an  excess  of 
indican,  phenolcresol,  etc.,  in  the  urine; 
this  intestinal  putrefaction  may  be  due 
to  the  peristaltic  inertia  common  at 
about  the  time  of  puberty.  Although 
further  investigations  are  needed  to 
demonstrate  the  causal  connection  be- 
tween acne  and  excessive  intestinal 
putrefaction,  the  writer  tried  the  effect 
in  cases  of  acne  of  drugs  which  have 
an  anti fermentative  action  and  which 
aid  peristalsis,  and  with  this  object  has 
administered  a  combination  of  1  gram 
of  sulphur  precipitate  and  0.25  gram 
of  menthol,  given  two  or  three  times 
a  day  over  a  period  of  several  months. 
In  the  33  cases  of  acne  mentioned, 
which  included  cases  of  acne  simplex, 
acne  pustulosa,  and  acne  indurata,  treat- 
ment on  these  lines  was  very  successful, 
substantial  improvement  being  seen  in 
all  the  cases  and  recovery  in  many. 
In  1  case  the  medicine  gave  rise  to 
diarrhea  with  colic-like  pains,  but  in 
the  others  there  were  no  unpleasant 
side-effects.  The  first  result  of  the 
treatment  was  that  the  stools  became 
pultaceous  and  the  output  of  phenol 
sank  to  0.01,  or  at  the  highest  to  0.07, 
as  opposed  to  an  average  output  of  0.101 
gram,  which  had  been  previously  ob- 
served. With  this  fall  in  the  output 
of  phenol  improvement  began,  and 
often  in  the  first  three  or  four  weeks 
the  acne  papules  were  observed  to  more 
quickly  disappear  ;  during  the  next  four 
in  eight  weeks,  in  all  but  1  obstinate 
case,  new  papules  appeared  with  much 
less  frequency,  and  in  9  cases,  after 
three  months'  treatment,  no  new  pap- 
ules formed.  Some  of  the  cases  have 
now  been  as  long  as  eighteen  months 
without  relapse,  and  may  be  considered 
to  have  completely  recovered.  During 
the  internal  treatment,  local  treatment, 
although  it  was  not  altogether  discon- 
tinued, was  reduced  to  a  minimum. 
Josef  Kapp  (Therapeutische  Monats., 
March,   1907). 

It   has   been   also   alleged   without, 
however,    substantial    foundation    that 


ACNE    (STELWAGON). 


259 


lesions  of  the  g-enitoiirinary  oi\qans 
and  venereal  excesses  may  proA^oke 
the  disease.  Lesions  may  be  due  to 
mechanical  irritation  caused  by  the 
product  of  secretion  remaining  in  the 
excretory  canal  or  gland  itself.  Some 
drugs,  as  already  stated, — such  as  the 
bromides  and  iodides,  —  are  occa- 
sionall_v  responsible  for  the  eruption 
or  an  increase  in  an  already  existing 
eruption.  Certain  drugs  applied  ex- 
ternally may  also  provoke  acneic 
lesions,  such  as  tar  and  tar  products, 
juniper  oil,  and  the  like.  Workers  in 
paraffin  and  paraffin  products  will  not 
infrequently  be  found  affected  Avith 
papules  and  pustules,  especially  those 
of  a  furuncular  or  abscess  type.  The 
direct  local  exciting  factor  is  thought, 
by  many,  to  be  a  micro-organism, 
Gilchrist's  observations  pointing  to 
a  specific  bacillus. 

Up  to  1899  no  observer  had  succeeded 
in  obtaining  the  acne  bacilli  pure  from 
lesions  of  acne  vulgaris  or  comedo,  and 
there  was  practically  no  proof  that 
these  bacilli  were  the  cause  of  acne 
vulgaris.  Definite  bacilli  (Bacillus 
acnes),  however,  were  found  present 
in  all  smears  taken  from  240  typical 
acne  lesions  from  86  patients.  Pure 
cultures  were  obtained  from  62  lesions 
(chiefly  acne  nodules)  from  29  patients. 
It  is  present  as  a  short,  thick  bacillus 
in  smears,  but  in  culture  often  becomes 
much  longer  and  thicker,  and  in  old 
cultures  assumes  distinct  branching 
forms.  It  is  now  definitely  proven 
that  this  micro-organism  is  the  primary 
cause  of  acne  vulgaris.  T.  C.  Gilchrist 
(Jour,  of  Cutan.  Med.,  Mar.,   1903). 

PATHOLOGY.— In  most  cases  the 
process  begins  by  a  perifolliculitis, 
which  later  on  gives  rise  to  a  purulent 
folliculitis.  It  would  thus  seem  that 
in  some  cases  the  sebaceous  glands 
play  but  a  small  part  in  the  affection. 
In  most  cases,  however,  when  come- 
dones are  present,  the  sebaceous  gland 


itself  is  the  starting  point  of  the  in- 
ilammatory  process.     (lirocq.) 

Even  when  the  focus  of  irritation  is 
in  the  follicle,  it  is  frequently  limited 
to  the  sebaceous  or  sebaceous  pilary 
canal.     (E.  Besnier,  A.  Doyon.) 

The  papillae  surroundin,?  the  come- 
done  and  the  superficial  layers  of  the 
corium  are  filled  with  blood-vessels 
full  to  repletion,  and  of  exudation  cells 
which  are  found  in  dilated  vacuoles. 
(Kaposi.) 

If  the  process  is  very  intense,  the 
sebaceous  gland  may  be  entirely  de- 
stroyed by  the  local  inflammatory 
action,  while  the  pilar  bulba  persists. 
(Kaposi.) 

The  acneic  process  may  be  divided 
into  two  parts:  1.  Closure  of  the 
sebaceous  follicle  and  formation  of 
comedo.  2.  Suppuration,  which  only 
occurs  in  those  follicles  where  the 
staphylococci  aureus  et  albus  have 
penetrated  before  the  comedo  formed. 
(Unna.) 

The  writers  have  succeeded  in  grow- 
ing the  Bacillus  acnes  under  anaerobic 
conditions.  It  stains  by  Gram's  method 
and  often  shows  an  irregular  or  beaded 
appearance.  It  is  moderately  wide  and 
of  variable  length,  especially  in  cultures, 
where  it  frequently  shows  branching 
forms.  It  forms  no  spores.  Abstract- 
ing oxygen,  by  Wright's  method,  it 
grows  on  all  the  common  media,  best 
on  glucose  agar,  either  in  suspension 
or  slant.  In  bouillon  it  forms  a  white 
flocculent  sediment.  It  was  most  easily 
grown  from  the  lesions  by  smearing 
the  pus  on  the  surface  of  glucose-agar 
slants.  On  this  medium,  in  the  absence 
of  oxygen,  it  produces  fair-sized  colo- 
nies in  three  to  five  days.  It  forms 
raised,  grayish-white,  opaque  colonies, 
considerably  smaller  than  those  of  the 
staphylococcus  albus,  which  are  purer 
white.  On  acid  agar,  as  noted  by  Flem- 
ming,  it  grows  in  the  presence  of  oxy- 
gen, but  much  more  slowly.  The  ba- 
cillus   is,   therefore,    essentially   an   an- 


260 


ACNE    (STELWAGON). 


aerobe,  but  will  grow  in  the  presence 
of  oxygen  when  planted  in  masses,  by 
reason  of  the  anaerobic  conditions  which 
are  thereby  created  within  the  masses. 
They  regard  this  bacillus  as  identical 
with  the  Bacillus  acnes  of  Gilchrist  and 
other  observers  from  its  similarity  in 
morphology  and  cultural  characteristics. 
From  the  ease  with  which  it  could  be 
obtained  from  their  cases  when  grown 
anaerobically,  they  think  it  can  probably 
be  cultivated  from  all  cases  of  acne. 
Hartwell  and  Streeter  (Boston  Med. 
and  Surg.  Jour.,  Dec.  16,  1909). 


TREATMENT.— In  this  connec- 
tion acne  may  be  divided  into  (1)  an 
irritable  or  inflammatory  variety,  in 
which  the  skin  is  fine  and  thin  and 
easily  irritated  by  stimulating  applica- 
tions, and  where  general  treatment  is 
important  on  account  of  the  close 
union  between  the  acneic  eruption 
and  various  constitutional  disturb- 
ances. Local  treatment  should,  at 
first  at  least,  be  of  a  mild  character. 
(2)  An  indolent  variety,  where  the  in- 


Bacillus  acnes  {Ilartioell  and  Streeter) 
Boston  Medical  and  Surgical  Journal,  Dec,  16,  1909. 


DIAGNOSIS.— Acne  is  to  be  dif- 
ferentiated from  the  papular,  papulo- 
pustular,  and  pustular  syphiloderms, 
:and  also  from  variola. 

.Syphilis. — In  the  syphilitic  eruption 
the  distribution  is  more  or  less  general, 
and  more  acute  in  its  outbreak,  darker 
hued,  and  occurring  occasionally  with 
gpecial  groupings  and  the  presence  of 
other  symptoms  of  the  disease. 

Variola.— In  small-pox  the  premoni- 
tory constitutional  symptoms,  the  sud- 
den outbreak,  the  uniformity  of  the 
lesions,  and  many  other  symptoms  of 
differential  character  will  serve  to 
differentiate. 


tegument  is  thick,  rough,  and  oily,  with 
enlarged  and  obstructed  gland  orifices, 
and  where  the  most  energetic  local  ap- 
plications are  well  borne ;  here  the  local 
treatment  is  important.  Probably 
most  of  the  cases  met  with  occupy  a 
middle  ground  between  these  two  ex- 
treme varieties. 

General  Treatment.  — ■  Prophylactic 
measures,  such  as  the  avoidance  of  ex- 
ternal irritants,  drugs  and  food  hable 
to  cause  acne,  such  as  coffee,  tea, 
alcohol,  pure  wine,  pork,  veal,  game  too 
far  gone,  preserved  fish,  shellfish,  fats, 
and  cheeses. 

Any  disorder  of  digestion  must  be 


ACNE    (.STELWAGON). 


261 


counteracted  in  ortler  to  avoid  the  con- 
gestion of  the  face  following  meals. 

If  the  tongue  is  much  coated  and 
shows  prominent  papillae,  the  following 
is  recommended : — 

I^  Sodium  bicarb 10  grs. 

Ext.  cascara  sagr.  liq 10-20  mins. 

Tiiiit.  mix  vomica   7-10  mins. 

Pcppcniiiiit  zcatcr.. to  make  1  fl.  oz. — M. 

Constipation  should  be  counteracted 
by  g'entle  aperients.  Any  condition 
capable  of  maintaining  the  sympathetic 
system  in  a  state  of  tension — such  as 
genitourinary  troubles  or  affections  of 
the  nasal  fossse — should  be  eradicated 
if  possible. 

If  the  patient  is  lymphatic  and  has  a 
good  digestion,  codliver  oil  is  of  value. 

Anemia  or  chlorosis  calls  for  the  use 
of  chalybeates  with  arsenic.  Iron  often 
does  harm  unless  its  constipating  effect 
is  counteracted  by  using  aperients. 
When  the  patient  is  arthritic,  alkalies, 
especially  alkaline  waters,  are  indicated. 

No  really  specific  treatment  is  known 
against  acne,  but  the  following  have 
been  recommended : — 

Sulphur  alone :  powder  or  tablets, 
or  with  equal  parts  of  honey. 

Ichthyol  (Unna)  : — 

R  Ichthyol 1-2  drs. 

Dist.  water  5  drs. 

M.  Sig. :  Fifteen  to  50  drops  in  water, 
to  be  taken  morning  and  evening. 

Arsenic  bromide  in  weak  doses,  %o 
grain,  in  acne  pustulosa.     (Piffard.) 

Mercurial  preparations,  such  as 
corrosive  sublimate  or  calomel,  either 
alone  or  Avith  jalap  or  colocynth  ex- 
tract, have  been  found  useful. 

The  writer  strongly  recommends  the 
old  mistura  acidi  ferri,  or  Startin's 
solution,  in  plethoric  girls  with  cos- 
tiveness,  coated  tongue  and  local  hy- 
peremia,   The  rnixture  is  as  follows; — - 


li  Magnesii  sulph 3j   (30.00). 

Ferri  sulph gr.  x  (0.65). 

Sodii  chloridi   3ss  (1.95). 

Acidi  sulph.  dil 3ij   (8.00). 

Infiisi  gent q.  s.  ad  5iv  (120.00). 

As  to  the  local  treatment :  1.  Wash 
the  face  well  at  night  with  cold  or  tepid 
water  and  good  soap;  tincture  of  green 
soap  is  desirable.  Open  with  a  sharp 
lance  all  pustules,  scrape  off  the  acne 
tops,  use  the  comedo  expressor,  dry 
the  face  and  whiten  with  the  white 
lotion.  2.  In  the  morning  flick  off  the 
white  powder  with  a  soft  towel.  It  is 
not  then  necessary  to  wash  the  face. 
Use  the  ointment  of  sulphur  in  the 
morning  if  the  skin  feels  dry  and  harsh 
in  spots  or  places,  or  apply  the  lotion 
lightly  if  about  the  house.  3.  On  going 
out  use  the  powder  as  a  cosmetic,  and 
at  night  wash  the  face  and  begin  the 
treatment  again.  Brayton  (Jour.  In- 
diana  State   Med.   Assoc,   Apr.,    1908). 

Summary  of  treatment:  Prohibit 
cakes,  pies,  pastries,  salt  meats,  fish, 
and  eating  between  meals.  If  anemic, 
give  nourishing  foods.  Ferri  citratis, 
5ij;  magnesii  sulphatis,  3v;  strych- 
ninae,  gf.  j;  syr.  zingiberis, '  §j ;  aquse, 
5iv.  In  obese,  constipated,  and  slug- 
gish individuals:  Potassium  acetate, 
3v;  fl.  ext.  of  carcara  sagrada,  Bij;  fl. 
ext.  of  rumex,  Biij;  1  dram  in  water 
half-hour  before  meals.  Outdoor  ex- 
ercise. Where  comedones  or  pus- 
tules: Green  soap,  3j;  resorcin,  5j; 
salicylic  acid,  gr.  v;  rose-water  oint- 
ment, §ij;  to  be  applied  at  night  and 
washed  off  in  morning,  until  fair  des- 
quamation obtained.  Lotio  alba  (po- 
tassium sulphide  and  zinc  sulphate) 
applied  at  night  after  using  hot  or 
cold  water;  friction  with  towel.  Cocks 
(Med.  Record,  Dec.  3,  1910). 

Local  Treatment.  —  Constitutional 
treatment  will  rarely  succeed  alone, 
while  in  a  large  proportion  a  local  treat- 
ment by  itself  will  be  found  efficacious. 

The  majority  of  cases  can  be  greatly 
benefited  ,in  a  short  time,  and  very 
many  of  them  cured  promptly.  The 
indications  for  treatment  are  as  fol- 
lows :   The  condition  of  the  skin  should 


262 


ACNE    (STELWAGON). 


be  improved  so  that  it  will  no  longer 
be  a  suitable  culture  ground  for  the 
bacillus.  The  follicles  of  the  skin 
should  be  emptied  of  the  colonies  of 
bacilli.  The  skin  should  be  constantly 
kept  aseptic,  so  that  any  bacilli  that 
escape  on  it  will  be  killed,  and  no  new 
infection  of  the  skin  will  be  possible. 
The  first  indication  is  met  by  attention 
on  the  patient's  general  health  by  means 
of  baths,  diet,  exercise,  attention  to 
hygiene,  and,  lastly,  drugs.  The  folli- 
cles are  emptied  by  the  use  of  the  cu- 
rette, the  acne  lancet,  and  the  comedo 
expressor.  The  best  local  application  is 
sulphur,  preferably  in  the  form  of  the 
old  lotio  alba,  the  formula  for  which  is : 
Zinc  sulphate  and  potasE:ium  sul- 
pheret,  of  each,  3i-ij ;  rase  water,  q.  s. 
ad  §iv.  This  is  to  be  shaken  up  before 
using.  Resorcin  is  also  useful,  as  well 
as  sulphur  soap.  The  use  of  the 
Roentgen  ray  should  be  limited  to  in- 
tractable cases,  and  requires  great 
caution  to  prevent  doing  harm.  G.  T. 
Jackson  (Med.  Rec,  Mar.  IS,  1905). 

Hot-water  and  alcoholic  lotions 
sometimes  act  promptly.  In  mild  cases 
these  are  applied  at  night  with  very 
hot  water,  either  pure  or  combined 
with  cologne  water  or  camphorated 
alcohol.  The  water  is  gradually  re- 
duced until  pure  camphorated  alcohol 
or  cologne  water  is  used.  Boric  acid 
or  borax  may  be  added  to  the  lotions : 
1  part  to  50. 

Night  and  morning  the  skin  should 
be  bathed  in  very  hot  water  (to  re- 
duce the  congestion),  to  which  creolin, 
or  a  few  drops  of  the  following  solu- 
tion,  should  be  added : — 

B  Corrosive  sublimate   7^  grs. 

Tinct.  of  benzoin  .......       75  grs. 

Emulsion  bitter  almonds.  3675  grs. 
M. 

E.  Lacour  (Nord  med.,  Aug.  15, 
1900). 

Many  of  the  less  severe  forms  can 
be  cured  by  prolonged  bathing  in  hot 
water.  The  water  should  be  soft,  and 
the  applications  to  the  face  should  be 
made  with  a  soft  bathing  sponge.  The 
gponge,   loaded    with   water    as    hot    as 


can  be  borne,  should  be  applied  to  the 
face.  The  bathing  should  last  about 
five  minutes,  and  should  be  done  each 
night  and  morning ;  at  the  same  time 
moderate  pressure  is  applied  to  the 
sponge.  After  the  sponging  the  face 
should  be  dried  on  a  soft  towel  without 
rubbing,  and  bay  rum  should  be  applied 
freely.  The  face  should  not  be  touched 
by  the  hands  until  the  time  for  repeat- 
ing the  process.  W.  L.  Hunt  (Jour,  of 
Med.  and  Sci.,  Sept.,  1904). 

Have  patient  vigorously  scrub  his 
face,  every  night  before  retiring,  with 
green  soap  and  hot  water.  After  rins- 
ing with  cold  water  and  drying  the  face, 
the  following  paste  is  to  be  applied : 
Betanaphthol,  5  parts;  precipitated 
sulphur,  25  parts;  green  soap  and 
lanolin,  of  each,  35  parts.  Spread  this 
over  the  involved  crea  and  allow  it  to 
remain  fifteen  minutes  to  one  hour, 
after  which  it  is  wiped  off.  Length  of 
application  depends  on  the  reaction 
produced;  if  left  on  too  long,  the  skin 
reddens,  or,  after  greatly  prolonged 
contact,  the  epidermis  desquamates. 
This  paste  acts  probably  by  causing 
an  inflammation  of  the  skin,  which 
extends  along  the  dilated  follicles, 
thus  inhibiting  the  secretion  and  pro- 
ducing shrinkage  of  the  dilated  seba- 
ceous glands.  When  the  condition  is 
improved,  continue  the  applications  at 
longer  intervals  to  prevent  recur- 
rence; also  scrub  face  every  second  or 
third  night.  Burke  (Penna.  Med. 
Jour.,  March,  1911). 
Instead  of  camphorated  alcohol  there 

have  been  used  with  success : — 

Alcohol,  96°,   saturated  with  boric 

acid,  and  alcohol  with  salicylic  acid,  1 

to  ZO.    The  latter  is  strong  and  must  be 

used  with  care. 

Mercurial    preparations    have   been 

variously    extolled,    but    in    late    years 

have  gradually  given  way  to  other  more 

valuable  remedies. 

Mercurial  lotions  are  efficacious  in 

some  cases,  employed  as  follows : — 

I^  Corr.  subl 1  part. 

Alcohol,  90°  100  parts. 

Dist.  lijater  or  rose  water  . . .    150  parts. 


ACNE    (STELWAGON).  263 

At    first    this    solution    is    weakened  of  the  disease;  especially  useful  when 

with    one-half    its    quantity    of    water;  much     seborrhea    exists.       In    a     few 

afterward,  if  no  irritation  lias  resulted,  ])atients  sulphur  preparations  cannot  be 

the  water  is  gradually  rcducetl  until  the  used,   owing   to    the    irritation    caused, 

solution  is  employed  pure.  Sulphur  may  be  employed  in  the   fol- 

Other    mercurial    preparations,    in  lowing  ways : — 

ointment   form,   such  as  the  biniodide,  Sulphur  soap:     with  hot  water,  the 

the  iodochloride,  white  precipitate,  and  suds   being   allowed   to   dry   on   to   the 

mercurial  plaster,  viz. : —  face. 

l"he    ammoniated    mercurial    oint-  Sulphur  baths, 

ment,    5    grains,    or    30    grains    to    1  Sulphur  lotions:     hot  water  with  10 

ounce,    is    highly    recommended    by  to  60  drops  for  every  one-half  glassful 

Stopford  Taylor.  ^f  liquid  potassium  polysulphide. 

Gordon    Campbell    recommends    the  ^n  effective  method  of  using  sulphur 

followmg  procedure:—             ^  is  the  following:— 

The  face  is  to  be  washed  with  water  a  ff^,.   ^.^c-in;,.^.  ,  .vi     i    ♦.        j.            i 

Alter   wasnmg  with   hot   water   and 

as  hot  as  can  be  borne  and  some  bland  ^^^p^  ^j^^  following  mixture  is  applied 

unirntatmg  soap,  and  then,  after  care-  ^^j^h  a  camel's  hair  brush:— 
fully    drying    the    skin,    the    following 

lotion  is  applied  once  a  day:—  ^  Precipitated  sulphur. 

Potassium  bicarbonate, 

R  Hydrargyri  chloridi  corrosivi.   12  grs. .  Glycerin 

Spiritiis  vini  rcctif 6  oz.— M.  j^^^^^^^  ^^^^,,^ 

Effect   for  first  few  days  will  be  to  Alcohol ^(^0°)   of  each  2  drs.-M. 

render  condition  worse;  but,  after  this,  ji^g  coating  is  left  on  during  night- 

the  lotion  prevents  perforation  of   the  time   and   washed   off   in   the   morning 

pustules.  with  an  emulsion  of  almond  oil,  and 

External  _  drug    treatment     in    both  the  skin  is  covered  with  oxide  of  zinc 

acne  vulgaris  and  acne  rosacea  is  usu-  ,  .          ^,         ,     ., 

11     1-           •  ,•         e  1  1-      •    ^1.    u    .  01"  bismuth  subnitrate  ointment  pow- 

ally  disr.ppointing.    Sulphur  is  the  best  .                                           ^ 

external  preparation.    Mechanical  treat-  ^^^^^  O^er  with  fine  starch. 

ment,  such  as  the  use  of  hot  water,  When  the  skin  becomes  irritated,  the 

soap,  massage,,  and  the  dermal  curette,  sulphur    paste    should    be    discontinued 

is  exceedingly  valuable.    The  opsonic  ^„  j    ,i  „    „:^„   ^:    t.^^      ^           i-    j      i 

,     ■,  .                 ,       .    .             .  .  and  the  zinc  ointment  applied  alone 

method  m  acne  vulgaris  is  promising.  ......                  i. 

Roentgen  treatment  of  both  diseases  ""*^^  ^^^  irritation  has  disappeared, 

is  the  most  valuable.     In  its  certainty  The  following  are  Useful : — 

of  cure  and  frequency  of  relapse  it  al-  ^    _   ,  ,           .     . 

,                 ,                    -r        T^,      ,     ,  ii'  Sulphate  of  zinc, 

most  approaches  a  specific.      Ihe  tech-  <-   7   r             r             ■ 

„•          r      •       ^u    V                  •               •  Sulphuret  of  potassiuin..oi  each  1-4  drs. 

nique  of  using  the  X-ray,  say,  in  acne,  is  '               ^  ^ 

of  paramount  importance.     If  the  ray  is 4  oz. 

properly   applied  there   should  be   few,  u    n       -u       7^/ 

.^          \  .,               ,               ,     .     ,  ,       ,  I>  Precip.  sulphur, 

if  any,  failures  and  no  undesirable  ef-  ^.r                                       r        i    ^    i 

,    ,       ^  .      ,-,          -r    J-         c.  .     TIT  J  hther of  each  4  drs. 

fects.     Cole   (Jour.  Indiana  btate  Med.  u     i    i                            ,          ,      a  n 

Assoc,  Mar.,  1909).  ^-^'^"^'"^ ^^  "^^'^^^  ^  fl.   oz. 

Formaldehyde,  largely  diluted,  has  ^  ^/''^^-  •^".^^^""', 2  drs. 

,     ,              .    ,      .  1  Gum  tragacanth, 

recently  been  tried  with  success.  /-„„,a?^.                         c       i    or. 

•'  Camphor of  each  20  grs. 

Sulphur  preparations  are  by  far  the  Lime  water  2  fl.  oz. 

most  valuable  in  the  external  treatment  Water  . .  ■  ■ to  make    4  fl.  oz. 


264  ACNE    (STELWAGON). 

Both    these    lotions    are    often    made  is    applied.      In    acne    vulgaris,    after 

more  valuable  by  the  addition  of  2  to  5  steaming,  strong  sulphur  and  ichthyol 

,               .  soap  is  used  with  brisk  rubbing  with 

per  cent,  of  resorcm.  a    u    i           -n         v     r-\j   \r   t 

^  a  iiesh-glove.     Brownlie   (N.    Y.   Lan- 

Sulphur  ointments  are  usually  made  ^^^   -^^^     1901) 

.in  the  proportion  of  1  in  10,  with  benzo-  The  '  followin-    resorcin    paste    is 

ated  lard,  smiple  cerate,  vaselm,  vaselin      recommended : 

and  lanolin,  lanolin  and  sweet  almond  .                               or/  c       . 

-t>  Resorcm    2>2-5  parts. 

oil  or  olive  oil,  or  castor  oil  and  cacao  ^^^^^  oxide 

butter.  Starch    of  each     S  parts. 

To  the  sulphur  may  be  added  oxide  Vaselin    125^  parts.— M. 

of  zinc  in  equal  parts ;  borax,  1  to  20 ;  This  paste  may  remain  on  a  day  and 

salicylic  acid,  1  to  50;  naphthol,  1  to  a  night   and   then  be   removed   with   a 

10  or  1  to  20;  resorcin  or  camphor,  1  piece -of   cotton.      Cure   is    said   to   be 

to  20  or  1  to  40.     They  may  be  per-  speedy,  occurring  in  three  or  five  days, 

fumed  with  essence  of  rose,  bergamot,  It  is  a  strong  preparation,  acting  with 

or  balsam  of  Peru  if  desired.  considerable  energy  in  some  cases. 

Sulphur  soaps  are  sometimes  more  In  slight  cases  of  acne  of  the  face 

convenient  ^^^  following  formula  is  recommended : 

T^i      j:   11       •        ™       1^^  ,.r.^A  .  Eau  de  cologne,  or  90  per  cent,  alco- 

The  f  ollowmg  may  be  used : —  -^  i      •  ,              •             ^■     ^■        -jo 

.    .                                         .  hoi,  with  resorcin  or  salicylic  acid,  2 

Soap  and  precipitated  sulphur,  equal  ^^  ^  ^^^  ^^^^^  ^^  sublimate  or  cyanide 

parts.  of  mercury.     After  these  lotions  the 

Soap,  precipitated  sulphur,  and  lard,  skin  should  be  slightly  greased  with 

equal  parts  lanolin,  10;  water,  20;  and  rose  water, 

Naphthol  may  be  cautiously  added  ^     parts.      The     application     of     an 

aqueous  solution  of  ichthyol,  5  to   10 

to  the  first  of  the  series.  p^^    ^^^^_^    ^^    ^j^^    ^^^^^1      Leredde 

Among  other  local  treatments  recom-  (b^h^  g^^.  de  therap.,  1903). 

mended  are  the  application  to  the  pus-  Salicylic  acid  acts  well  in  from  1  to 

tules  of  carbolic  acid,  salicylic  acid,  or  31^  per  cent,  in  various  ointments. 

resorcin.     An  ointment  of  ichthyol,  1  Electrolysis  has  been  recommended 

to  4  or  1  to  8,  is  also  useful.  f^j.    ^he     removal    of     the    indurated 

Ichthyol  is  very  beneficial  both  in  masses  left  on  the  skin, 

acne  vulgaris   and   acne   rosacea.     The  i^    ^^^^    ^f    ^^e    back    the    strongest 

best  results  are  obtained  when  external  r      -•                             1                  1            a   a 

...  applications,  as  a  rule,  are  demanded, 

and   internal   treatments   are   combined.  ^^                                  . 

In  some  cases  of  acne  rosacea  in  which  ^i  especial  value  m  some  cases  is  the 

the  skin  is  too  thin  and  irritable  to  bear  liquor  calcis  sulphuridis  (Vleminckx's 

even   weak   solutions,   the    internal   ad-  solution).    This  should  be  used  at  first 

ministration    of     ichthyol    alone,     with  diluted. 

steaming,  will  be  beneficial.    Five  grains  Massage    of    the    face    is    not    to    be 

of  ichthyol  may  be  given  thrice   daily,  7    ,    r 

after   food,   increasing  the   amount  to  commended  for  acne,  often  doing  dis- 

10   grains.     Every  night   and  morning  tinct  harm. 

the  face  is  steamed  for  fifteen  minutes,  The  comedo  is  in  the  majority  of 
and  is  then  washed  with  ichthyol  soap.  cases  the  forerunner  of  the  acne  nodule 
The  lather  is  allowed  to  dry  on  the  and  pustule.  The  comedo  is  best  re- 
face,  after  which  it  is  gently  washed  moved  by  a  comedo  extractor,  which 
off  with  water.  After  each  washing  should  have  rounded  edges.  The  pres- 
ichthyol  salve,  if  it  can  be  borne  (often  sure  should  be  moderate,  and  if  the 
combined   with   ammoniated   mercury),  comedo    does   not   escape   it   is  best  to 


ACNE    (STELWAGON). 


265 


puncture  with  a  narrow  bistoury.     This 
should  be  done  by  the  physician.     The 
papules    and    pustules    arc    treated    by 
lancing.     When  more  active  methods 
are  not  employed,  it  is  of  value  to  cover 
the  parts  with  mercurial  plaster  for  a 
few    nights.      Various    useful    methods 
have  been   devised,  the  main  local  ap- 
plications consisting  of  sulphur,  sali- 
cylic  acid,   resorcin,   and    soap.     The 
best    treatment,    however,    is    the    X- 
ray.     In  many  cases  irradiations  will 
obviate   the   necessity   of   lancing   the 
nodules   and  pustules.     D.   Lieberthal 
•      (Lancet-Clinic,  Dec.  30,  1905). 
Before   undertaking  the   local   treat- 
ment of  acne  it  is  well  to  open  the 
pustules,    empty   the   comedones   and 
sebaceous  cysts,  etc.    These  measures 
often  prove  satisfactory  in  indurated 
and  rebellious  acne.     Some  observers 
object,    however,    to    the    use   of    the 
curette. 

Facial  acne  gives  favorable  results 
under  treatment  by  a  glass  vacuum 
electrode  excited  by  the  Oudin  reso- 
nator and  transmitting  quite  a  strong 
current.  The  bulb  should  be  rubbed 
over  the  skin  without  breaking  the 
contact,  and  at  the  same  time  a  con- 
stant stream  of  tiny  violet  sparks 
should  pass  from  parts  of  the  bulb 
not  in  the  closest  contact  with  the 
skin.  The  face  should  be  somewhat 
red  after  an  application  lasting  six  or 
eight  minutes  during  which  the  elec- 
trode is  in  constant  motion.  The 
writer  is  most  strongly  opposed  to 
the  rractice  of  opening  acne  pustules. 
He  has  seen  faces  as  badly  marked 
as  by  small-pox.  It  seems  much  bet- 
ter to  treat  the  ase  along  the  follow- 
ing lines:  Rhubarb  and  soda  inter- 
nally relieve  any  source  of  irritation, 
such  as  phimosis;  cleanse  the  skin  by 
vigorous  washirg  with  tar  soap  every 
night  and  then  apply  a  soothing  anti- 
septic salve,  such  as  ung.  zinci  oxidi, 
2  ounces  (62  Gm.)  ;  pulv.  acidi  salicyl., 
20  grains  (1.3  Gm.).  This  treatment 
combined  with  that  by  high-frequency 
currents  has  enabled  the  author  to 
permanently  cure  a  number  of  cases 
of  acne  vulgaris  and  the  disagreeable 


and  intractable  acne  rosacea.  Sin- 
clair Touscy  (Amer.  Jour,  of  Dermat., 
Oct.,  1911). 

Alild  X-ray  exposures  of  short  dura- 
tion and  low  vacuum  may  often  be 
advantageously  employed,  but  should 
be  done  with  great  caution  and  as  an 
aid  rather  than  the  sole  measure  of 
treatment.  Its  indiscriminate  and  inju- 
dicious use  is  to  be  condemned. 

Treatment  of  acne  by  exposure  to 
the  X-rays  tried  in  15  cases.  With 
one  exception  satisfactory  results 
were  obtained.  The  cases  were  not 
selected.  R.  R.  Campbell  (Jour. 
Amer.  Med.  Assoc,  Aug.  9,  1902). 

In  acne  vulgaris  which  resisted  all 
other  forms  of  treatment,  the  X-rays 
acted  very  favorably.  It  caused  absorp- 
tion of  recent  papules,  and  crusting 
over  and  disappearance  of  pustules. 
The  best  results  were  obtained  after 
fairly  strong  cutaneous  reaction  took 
place,  as  indicated  by  marked  hyper- 
emia and  desquamation.  The  first 
effect  of  treatment  was  to  aggravate 
the  condition.  As  improvement  was  ob- 
served '  only  after  the  reaction  sub- 
sided, several. applications  were  neces- 
sary to  produce  a  cure.  Torok  and 
Shein  (Wiener  klin.  Rundschau,  Sept. 
13,  1903). 

Four  cases  of  acne  treated  with  the 
X-ray.  Two  were  entirely  cured, 
while  the  other  showed  very  marked 
improvement  and  were  nearly  free 
from  the  disorder.  The  duration  of 
the  disease  previous  to  its  use  varied 
from  sixteen  months  to  two  years. 
The  soft  tube  was  used  in  every  case 
at  a  distance  from  six  to  nine  inches, 
and  an  exposure  of  about  eight  min- 
utes. This  was  done  three  times  a 
week,  requiring  from  five  to  twelve 
exposures.  Slack  Atlanta  Jour.-Rec. 
of  Med.,  July,  1903). 

In  pustular  and  indurated  acne  time 
is  usually  lost  by  waiting.  Medication 
will  remove  comedones  and  produce 
desquamation,  but  it  has  as  little  effect 
on  the  overactive  sebaceous  glands  as 
has  the  X-ray;  in  pustular  acne  the 
rays  seem  to  have  a  fourth  action  on 
the    staphylococci    by    rendering    the 


266 


ACNE    (STELWAGON). 


soil  inert.  Care  must  be  taken  to 
avoid  undesirable  results;  this  is  in- 
sured by  using  a  very  low  vacuum 
tube  with  the  anode  at  eight  inches 
from  the  skin,  one  and  a  half  milliam- 
peres  of  current  and  from  five  to  ten 
minutes'  exposure,  according  to  the 
condition  of  the  patient.  Nine  treat- 
ments usually  show  how  much  more 
will  be  required,  and  what  variations 
of  the  treatment  are  needed.  R.  H. 
Boggs  (Jour.  Amer.  Med.  Assoc, 
Aug.  31,  1907). 

The  ray  treatment  and  the  passive 
hyperemia  treatment  have  much  in  com- 
mon. The  bactericidal  effect  of  the  rays 
lies  in  their  power  to  increase  the  local 
opsonic  index  just  as  it  is  increased  by 
the  old  treatments.  But  the  rays  also 
bring  about  a  vascular  constriction  and 
produce  atrophy  of  the  sebaceous  glands 
in  which  all  acne  begins.  The  uncer- 
tainty of  currents,  the  variance  of  tubes, 
the  personal  idiosyncrasy  of  the  patient, 
the  factors  of  knowledge  gained  by  ex- 
perience on  the  part  of  the  operators, 
must  all  be  given  weight,  and  these, 
collectively,  make  it  impossible  to  state 
in  any  given  case  what  the  result,  bene- 
ficial or  harmful,  of  ray  treatment  may 
be.  The  legal  rule  is  now  established 
by  precedent  that,  if  the  ray  operator 
possesses  and  exercises  the  average 
knowledge  of  the  treatment,  he  is  not 
responsible  for  the  injuries  that  may 
occur.  The  patient  should  always  be 
warned  of  the  dangers  of  the  ray  treat- 
ment. A.  W.  Brayton  (Jour.  Ind. 
State  Med.  Assoc,  Apr.  IS,  1908). 

Report  of  4  cases  of  very  disfiguring 
and  obstinate  acne  keloid  (dermatitis 
papillaris  capilliti  of  Kaposi)  success- 
fully treated  by  means  of  the  X-rays. 
It  produces  in  moderate  or  large  doses 
prompt  healing,  even  in  cases  which 
have  lasted  many  3'ears ;  in  some  in- 
stances a  single  sitting  may  be  sufficient 
to  bring  about  the  disappearance  of  the 
disease.  Kienbock  (Archiv  f.  Dermat. 
u.  Syphilis,  Bd.  xc,  H.  3,  1908). 

When  the  lesions  are  somewhat  in- 
durated, the  use  of  the  actinic  lamp 
twice  weekly  for  periods  of  from  fif- 
teen to  thirty  minutes  has  given  the 
writer  excellent  results  as  a  support- 


ing measure.  For  the  deeper  indura- 
tions the  X-ray  has  proven  very  use- 
ful, and  by  many  dermatologists  this 
is  the  method  of  choice.  It  is,  how- 
ever, in  the  long  run,  no  more 
successful  than  some  of  the  older 
methods,  and  should  be  reserved  for 
those  cases  which  are  obstinate  to 
other  forms  of  treatment.  The  in- 
jection of  vaccine  made  from  dead 
cultures  of  the  acne  bacillus  and  the 
staphjdococcus,  suspended  in  salt  so- 
lution, has  given  good  results,  and, 
in  the  writer's  opinion,  should  be 
given  the  preference  over  the  X-ray. 
The  reports  of  cases  treated  by  vac- 
cine therapy  also  show  it  to  be  a 
method  that  is  well  worthy  of  a  care- 
ful trial  in  rebellious  cases.  Sam- 
pliner  (Ohio  State  Med.  Jour.,  Feb., 
1910). 

According  to  Bier,  nature  always 
meets  a  pathogenic  substance  with  the 
same  weapon,  namely,  hyperemia.  This 
is  shown  either  by  scratching  a  sterile 
skin  with  a  sterile  needle  or  by  infect- 
ing any  organism  with  any  irritating  or 
poisonous  germ,  or,  most  commonly  of 
all,  by  the  reaction  of  the  part  when  a 
small  splinter  is  lodged  in  the  skin. 
The  object  is  to  increase  the  blood- 
supply  to  the  affected  or  the  infected 
part  and  by  so  doing  to  increase  the 
supply  of  leucocytes,  and  by  this  means 
either  to  destroy  the  infective  germs  or, 
by  an  increase  of  serum,  to  dilute  the 
poison  till  harmless,  or  to  wash  away 
the  debris  or  infection.  Bier's  method 
has  recently  been  tried  in  acne  with 
some  degree  of  success. 

Bier's  method  for  the  treatment  of 
acne  consists  in  the  application  of  dry 
cups  to  the  afifected  region  for  one-half 
hour  once  or  twice  a  day.  The  suction 
is  slight,  and  the  cup  is  removed  and 
reapplied  every  one  or  two  minutes. 
From  two  to  five  applications  must  be 
made  over  the  same  area  before  im- 
provement is  effected.  The  method  does 
not  prevent  the  appearance  of  new 
pustules,  though  they  become  less  fre- 


ACNE    (STELWAGON). 


267 


quent.  Eight  cases  treated  by  tliis 
method  alone  produced  m.irked  im- 
provement. E.  Moschowit/.  (Med.  Rec., 
Jan.   13,   1906). 

Bier's  suction  cups  found  useful. 
Applied  for  repeated  five-minute  pe- 
riods with  three-minute  intervals. 
Usual  1}'  two  to  hve  applications  at 
each  seance.  Considerable  degree  of 
congestion,  and  frequently  repeated 
treatment,  required,  first  to  large  af- 
fected areas  and  afterward  locally  to 
persistent  individual  comedones  and 
pustules.  Increases  local  blood-sup- 
ply, encourages  removal  of  deleteri- 
ous products,  activates  sweat-glands, 
and  promotes  action  of  drugs  locally 
applied.  Sibley  (Lancet,  Feb.  4, 
1911). 

Sir  A.  E.  Wright's  vaccine  therapy 
has  also  been  used  with  success  in  acne. 
As  this  investigator  explains,  no  attempt 
is  made  to  supply  to  the  patient  pro- 
tective substances  produced  in  the 
organism  of  an  animal  vicariously  in- 
oculated, but  the  chemical  machinery 
of  the  patient  is  induced  to  elaborate 
by  its  own  efforts  the  protective  secre- 
tion which  is  required  for  the  destruc- 
tion of  the  pathogenic  agent. 

Series  of  cases  illustrating  the  fact 
that,  while  in  some  cases  an  autogen- 
ous vaccine  of  acne  bacillus  is  neces- 
sary, experience  has  shown  that  in  the 
vast  majority  of  cases  great  improve- 
ment has  been  induced  by  the  inocula- 
tion of  a  stock  vaccine  combined  with 
staphylococcus  if  an  examination  of 
films  has  revealed  that  the  organism  is 
present.  The  dose  used  had  varied 
from  4,000,000  to  10,000,000,  and  the  in- 
terval between  inoculations  from  one  to 
two  weeks.  The  guide  to  treatment  has 
been  the  appearance  of  fresh  lesions, 
either  during  the  period  of  low  resist- 
ance following  the  positive  phase  when 
too  long  an  interval  has  been  allowed 
to  elapse  or  in  the  next  two  or  three 
days  after  an  inoculation  indicating  that 
too  large  a  dose  has  been  administered. 
By  watching  these  signs  and  working 
the  dose  up  till  it  just  fails  to  show  any 
"negative  phase"  clinically,  one  obtains 


the  maximum  benefit  from  the  vaccine. 
In  this  way  a  large  number  of  cases  of 
acne  in  all  its  stages  have  been  greatly 
improved,  and  in  a  fair  proportion  the 
lesions  have  totally  disappeared.  On 
cessation  of  treatment  in  several  in- 
stances, especially  in  some  cases  where 
attendance  ceased  before  the  condition 
had  entirely  disappeared,  there  was  a 
recrudescence  of  the  disease,  which, 
however,  rapidly  gave  way  to  subse- 
quent treatment.  Alexander  Fleming 
(Lancet,  Apr.   10,   1909). 

The  use  of  polyvalent  vaccine  (pre- 
pared from  cultures  of  staphylococcus 
albus,  citreus  and  aureus)  answers  well 
enough  in  most  cases,  especially  when 
there  is  much  pustulation.  When  the 
chief  feature  is  the  comedo,  an  acne 
bacillus  vaccine  is  indicated.  A  mixed 
vaccine  of  200,000,000  polyvalent  staphy- 
lococci and  8,000,000  acne  bacilli  is  what 
has  been  used  by  the  writer  in  recent 
cases.  The  dose  must  be  gradually  in- 
creased to  the  maximum  wijh  about  ten 
days'  interval,  and  the  efifects  very  care- 
fully watched.  He  has  found  the  treat- 
ment to  yield  brilliant  results  in  some 
cases,  while  in  others  the  condition  re- 
curs shortly  afterward.  Walsh  (Med. 
Press  and  Circular,  Jan.  26,  1910). 

The  treatment  of  acne  vulgaris 
with  suspensions  of  acne  bacillus  has 
proved,  in  the  author's  hands,  since 
a  proper  technique  has  been  adopted, 
the  most  brilliant  therapeutic  agent 
yet  seen  in  dermatology.  Some  of 
the  cases  respond,  as  does  the  mem- 
brane in  diphtheria,  to  its  antitoxin; 
nothing  else  in  medicine  can  compare 
with  its  action  in  favorable  cases. 
There  is  only  one  drawback  in  these 
very  favorabis  cases,  and  that  is  the 
lesions  undergo  such  complete  and 
rapid  involution  that  deeper  and 
more  marked  scars  supervene.  Noth- 
ing demonstrates  Wright's  negative 
phase  better  than  these  suspensions 
in  acne.  Invariably  two  or  more  new 
lesions  appear  within  forty-eight 
hours  after  the  injection.  If  a  large 
dose  is  given,  a  numerous  crop  can 
be  produced,  and  the  negative  phase 
prolonged  for  days.  By  repeated 
large  doses  a  mild  case  can  be  aggra- 
vated or  converted  into  a  severe  one 


268 


ACNE    ROSACEA    (STELWAGON). 


with  large  cystic  lesions,  and,  further- 
more, the  positive  phase  in  such  in- 
stances is  not  clinically  evident.  Such 
a  patient  remains  for  some  time  ex- 
tremely sensitive  to  any  dosage.  Such 
has  been  the  writer's  experience  with 
doses  of  50,000,000  at  seven-day  in- 
tervals, an  experience  repeated  sev- 
eral times  by  him.  Mild  cases  stand 
a  larger  dose  than  severe  ones;  in 
the  latter,  continuous  small  doses  give 
the  best  results.  Engman  (Interstate 
Med.  Jour.,  Dec,  1910). 

The  writer  found  in  28  successive 
cases  that  by  painting  an  acne  lesion 
with  old  staphylococcus  vaccine  it 
healed  rapidl3\  The  comedones  dried 
up  and  were  easily  removed  bj^  rub- 
Ling  with  a  coarse  tovv^el.  Moreover, 
tlie  large,  open  pores  became  con- 
stricted, leaving  a  perfectly  normal 
sl;in.  At  first,  the  application  caused 
redness  with  a  sharp,  stinging  pain 
that  lasts  a  few  minutes,  but  these 
phen®niena  become  less  marked  as 
additional  applications  were  made. 
Le  Roy  (N.  Y.  Med.  Jour.,  Dec.  31, 
1910). 

The  writer,  experimenting  v/itli  vac- 
cines derived  from  the  laboratories 
at  St.  Mary's  Hospital  in  cases  of 
acne,  either  simple  or  complicated  by 
suppuration,  and  with  the  addition 
of  no  local  treatment,  found  in  9 
cases  of  pustular  acne  with  come- 
dones manifest  improvement  in  the 
pustulation  after  the  injection  of 
mixed  vaccines  of  microbacillus  of 
acne  plus  staphylococcus.  In  8 
cases  the  eflfect  was  almost  nil;  in 
3  cases  there  was  temporary  ag- 
gravation of  the  pustulation,  prob- 
ably, as  the  author  says,  due  to  too 
close  approximation  of  dosage;  in 
2  cases  of  pure  comedo  formation 
there  was  pronounced  improvement. 
The  injection  consisted  of  5,000,000 
to  10,000,000  acne  bacillus  vaccine 
every  five  to  ten  days,  and  125,000,000 
to  250,000,000  staphylococcus  vaccine 
every  five,  ten,  or  fifteen  days. 
Lassueur  (Ann.  de  Derm,  et  de 
Syph.,  July,  1910). 

Henry  W.  Stelwagon, 

Philadelphia. 


ACNE  BACTERIN. 

TERiAL  Vaccines. 


See    Bac- 


ACNE  ROSACEA.— DEFI- 
NITION.— Acne  rosacea  is  character- 
ized by  a  chronic  congestion  of  the 
face,  causing  vascular  dilatations ;  and 
by  changes  in  the  cutaneous  glands  and 
tissues,  giving  rise  to  seborrhea,  inflam- 
matory acne,  and  hypertrophic  changes. 

SYMPTOMS.— The  nose  and  malar 
eminences  are  especially  prone  to  this 
disorder.  It  may  also  affect  the  fore- 
head, chin,^the  neighborhood  of  the  alse 
nasi,  the  cheeks,  and  less  commonly  the 
side  of  the  neck.  In  women  the  chin 
is  occasionally  invaded. 

There  are  three  forms  of  acne 
rosacea. 

The  first  is  the  erythematous  and 
tclangiectasic.  It  may  be  characterized 
by  temporary  congestive  spots  on  the 
face,  showing  themselves  especially 
after  meals  and  in  the  evening.  These 
spots  may  be  accompanied  by  no  other 
lesion.  This  form  is  usually  present  in 
connection  with  more  or  less  seborrhea, 
especially  on  the  nose,  which  is  gen- 
erally very  oily.  Again,  the  erythema- 
tous variety  may  be  characterized  by 
small  vascular  dilatations  on  the  nose 
or  malar  eminences,  which  dilatations 
develop  gradually,  unite  with  one 
another,  and  form  a  network.  This 
network  is  uniform  in  hue  at  a  dis- 
tance, but  nearby  may  be  seen  to  be 
formed  of  congested  surfaces  over 
which  are  spread  vascular  dilatations. 
This  degree  of  the  erythematous  form 
is  almost  always  accompanied  by  sebor- 
rhea, enlarged  nose,  and  dilated  glan- 
dular orifices,  especially  in  women 
toward  the  menopause  and  in  wine- 
drinkers. 

The  nose  may  be  slightly  violet 
hued  and  be  cold  to  the  touch. 


ACNE    ROSACEA    (STELWAGON). 


269 


The  second  form  is  the  erythematous 
acne,  or  true  aciic  rosacea.  In  addition 
to  the  erythematous  and  congestive 
feature,  there  may  be  found  in  this 
variety  a  true  acneic  and  acne-hke  ele- 
ment: papules,  pustules  and  tubercles 
or  nodules.  In  some  cases  the  acne  ap- 
pears before  the  congestion.  There 
is  a  congestive  red  base  with  fine 
vascular  dilatations  and  papulopustules 
of  various  sizes,  often  resting  on  an 
indurated  violet-red  base. 

In  this  variety  there  may  also  be  in- 
crease in  number  and  size  of  the 
vascular  dilatations,  increase  in  size  and 
depth  of  the  acneic  indurations,  and 
proliferation  and  hypertrophy  of  the 
derma. 

The  third  form  is  the  hypertrophic 
acne,  or  rhinophyma.  In  this  variety 
the  glandular  orifices  are  much  en- 
larged, while  the  glands  themselves  may 
be  ten  to  fifteen  times  increased  in  size. 
The  tissues  around  them  proliferate, 
forming  a  variety  of  pachyderma.  The 
nose  may  be  red  or  violet  hued,  covered 
with  enlarged  orifices,  greatly  increased 
in  size,  occasionally  reaching  consider- 
able dimensions  (the  so-called  Pfund- 
nase  of  the  Germans).  Its  exterior 
may  be  mammillated.     (Brocq.) 

Two  subdivisions  of  this  form  are 
rendered  necessary  by  the  difference  in 
the  pathology  of  each.  The  first, 
glandular,  presents  an  embossed  aspect, 
the  hypertrophy  being  due  especially 
to  hypertrophy  of  the  pilosebaceous 
glands ;  the  second,  elephantiasic,  pre- 
sents a  smooth  aspect,  being  due  to 
chronic  edema ;  there  are  also  vascular 
dilatations,  with  sclerosis  of  the  derma. 
(Vidal  and  Leloir.) 

ETIOLOGY. — Women  suffer  more 
than  men  from  the  erythematotelangi- 
ectasic  and  acneic  forms.  Men  only  suf- 
fer from  hypertrophic  acne.    It  usually 


appears  between  30  and  40  years. 
In  women,  rosacea  develops  usually  at 
from  30  to  45  years,  and  increases  de- 
cidedly toward  the  menopause,  after 
which  it  may  recede.  It  may  also,  how- 
ever, develop  at  puberty. 

In  young-  women  and  girls  acne 
rosacea  is  frequently  due  to  chlorosis, 
dysmenorrhea,  or  sterility.  In  some 
it  recurs  at  each  conception. 

Some  authorities  claim  that,  among 
the  constitutional  causes,  heredity  plays 
an  important  part. 

Cold  feet,  urethral  and  uterine  dis- 
turbances, and  constipation  are  also 
recorded  as  causes  of  the  disease.  Ex- 
ceptionally a  factor  in  acne  may  be 
found  in  the  mouth  or  teeth  and  be 
unilateral  if  the  cause  is  one-sided 
(E.  Besnier,  Doyon). 

Dyspepsia,  neuralgia,  hemicrania, 
working  with  the  head  inclined  forward, 
and  disease  of  the  nasal  fossse  are 
among  the  less  frequent  etiological 
factors  (which  affect  men  more  than 
women),  while  high  heat,  overheated 
rooms,  high  wind,  sea  air,  cold,  and 
cold  water  are  occasional  causes,  espe- 
cially in  men.  The  disease  may  become 
started  in  people  who  for  several  years 
have  indulged  in  excessive  hydrothera- 
peutic  treatment.     (Kaposi.) 

Certain  occupations  which  expose  to 
heat,  cold,  winds,  etc.,  such  as  those  of 
coachman,  baker,  smith,  fireman,  glass- 
blower,  may  also  become  primary 
causes  of  the  trouble.  Indiscretion  in 
diet  and  alcoholic  beverages  are  well- 
known  factors.  According  to  Kaposi, 
in  wine-drinkers  the  nose  is  bright  red. 
in  beer-drinkers  it  is  violet,  while  in 
spirit-drinkers  it  is  soft,  large,  and  dark 
blue. 

PATHOLOGY.— The  vascular  dila- 
tations of  the  face  have  been  considered 
by  some  authorities  as  due  to  circula- 


270 


ACXE    ROSACEA    (STELWAGON). 


tory  troubles  caused  by  compression  of 
the  veins  in  the  cranial  foramina. 

A  certain  paretic  condition  of  the 
vascular  walls  may  often  be  looked 
upon  as  a  cause.     (Brocq.) 

The  cutaneous  nerves  of  the  region 
afTected  have  been  found  normal  by  E. 
Eesnier.  According  to  Leloir  and 
\'idal,  however,  there  is  congestion  of 
the  deeper  venous  network  of  the  skin; 
dilatation  of  the  same  vessels  and  of 
the  perifollicular  vascular  network, 
their  walls  being  often  diminished  in 
thickness.  There  is  also  formation  of 
new  vessels. 

DIAGNOSIS.  — Lupus  Erythema- 
tosus. —  The  superficial,  congestive 
variety  shows  a  brighter  and  better 
defined  redness;  crusts  or  squamae  on 
tl:e  surface;  sharper  and  more  definite 
edges ;  greater  sensitiveness  to  pressure  ; 
slight  elevation  above  the  surrounding 
surface.  There  are  no  papules,  pustules, 
or  tubercles.  If  any  cicatrix  be  present, 
it  is  surely  lupus  erythematosus. 

Acne  telangiectodes  is  an  affection 
sui  generis,  and  not  identical  with  lupus 
follicularis  disseminatus;  but  it  is  iden- 
tical with  the  acnitis  of  Barthelemy, 
and  must  be  distinguished  from  the 
disease  known  as  folliculitis.  It  pre- 
sents no  sort  of  etiological  relationship 
to  tuberculosis,  and  should  be  separated 
from  the  tuberculomata  and  the  tuber- 
culides. It  does  not  take  its  origin  in 
the  sebaceous  glands  and,  therefore, 
does  not  belong  to  acne.  Pick  (Archiv 
f.  Dermat.  u.  Syphilis,  Bd.  Ixxii,  H.  2, 
1905). 

Circumscribed  Congestive  Sebor- 
rhea.— In  this  disorder  there  is  a  limited 
extent  of  patches,  shallower  and  more 
uniform  redness,  with  crusts  covering 
them. 

Sycosis  Coccogenica. — This  is  al- 
ways an  inflammatory  disease  of  the 
hair-follicles  and  perifollicular  tissues. 
There  are  numerous  papules  and  pus- 


tules, each  perforated  by  a  hair,  and 
often  capped  by  a  small  circular  scale. 
The  upper  lip  and  chin  are  sites  of 
predilection.  The  affection  is  usually 
painful. 

Congenital  adenoma  sebaceum  also 
has  a  special  location :  the  nasogenial 
furrow,  the  parts  around  the  nose, 
mouth,  and  chin.  It  presents  a  mam- 
millated  aspect,  and  its  predilection 
for  early  youth  and  its  normal  evolu- 
tion serve  to  establish  its  identity. 

Eczema. — Erythematous,  or  pustu- 
lopapular,  eczema  of  the  face  may 
som.etimes  present  diagnostic  difficul- 
ties. In  this  disease,  the  more  or  less 
constant,  and  usually  intense,  itching, 
the  serous  or  seropurulent  secretion, 
and  the  desquamation  will  suffice  to 
establish  the  diagnosis. 

Chilblains. — Changeableness  of  the 
lesions  and  pains  are  peculiar  to  this 
disorder. 

Acneiform  Syphilides. — Here  the 
manner  in  which  the  elements  are 
grouped,  the  long  duration  of  their 
evolution,  their  tendenc}^  to  ulceration, 
and  consecutive  cicatrix  are  important. 

Rhinoscleroma. — In  this  disorder 
there  are  hard  or  ivory-like  masses  im- 
bedded in  the  nose. 

PROGNOSIS.— Acne  rosacea  does 
not  always  increase;  it  may  remain 
stationary  or  even  recede,  especially  in 
women  after  the  menopause. 

TREATMENT.  — As  to  general 
treatment,  it  is  especially  necessary  to 
pay  strict  attention  to  the  good  condi- 
tion of  the  stomach  and  intestines,  by 
appropriate  measures  and  suitable 
diet.  Purgatives  are  absolutely  neces- 
sary from  time  to  time;  laxatives 
should  frequently  be  given  and  con- 
stipation should  be  avoided  (Brocq). 

In   many   cases,   especially  where   the 
hemoglobin    percentage    is    low    or    the 


ACNE    ROSACEA  CSTELWAGON).                                      271 

bowels  arc   sluggish   and   irregular,   the  H   Quinine  hydrobromate, 

use   of   Startin's   mixture   is   effective,  P.ryuiinc  .....of  each  30  grs. 

the  formula  for  which  is:—  Belladonna   extract   6-12  grs. 

,   ,     .  ,,, ,,  Lithium    hcnaoate    30  grs. 

I^  Magncsn   sull^liatts    -i^iX'  r     -a-     *        i     ;         •              .    . 

Ferri    sulpliatis    0.25  Excipient  and  glycerin q.  s. 

Acidi  sull>hurici  dihiti   ....       8.0  Misce.     For  forty  pills. 

Sodii    chloridi    •       2.0  before  each  of  the  two  prin- 

Intusi  gentiance q.  s.  ad  120.0  .     ,"=        , 

^.        .             rr^  1           i  1-1              c  }    ■  cipal  meals. 

Directions :    Take  a  tablcspoonful  m  >■ 

half  a  gobletful  of  water  one  hour  be-  ,-„     ,       ,            ,                      i       i         j  i    j 

fore  each  meal,  using  a  glass  tube  be-  Rhubarb  or  aloes  may  also  be  added 

cause    of    the    iron.'    If    there    is    any  j^  necessary. 

indigestion  this  prescription  may  be  al  ■  ^,       ,        ,     ,                   .                                , 

tcrnated  with  the  following:—  The  local  therapeutic  agents  are  the 

_    „      .                                       on  same  as  in  acne  vulj^aris;  though  some 

IJ  Papain  o.v  .     .     ,,            .     .          ^ 

Sodium  bicarbonate,  nTitable  varieties  oi  acne  rosacea  exist, 

Charcoal  of  each  IG.O  j^    -^    ^^gually    necessary    to    act    with 

Make    into    SO    tablets.      Directions:  „,_„,„  pnpr<rv 

Two  tablets  in  a  wmeglassful   of  hot  greater  eneigy. 

water  before  each  meal.  Hot  water  and  mercurial  prepara- 

J.    Philip    Kanoky    (Amer.   Jour,    of  ^^^^^  ^..^  ^f^^^  ^f  ^.^1^^       ?^Iercurials 

Clin.  Med.,  Aug.,  1908).  ^^^^    however,    much    inferior    to    the 

Proper    circulation    of    lower    hmbs  sulphur  preparations. 

should  be  insured  by  adequate  clothing.  The  following  has  been  employed  by 

Any  abnormal  condition  of  the  genito-  Bazin  with  success  :— 

urinary  tract  or  of  the  upper  respiratory         j^  Mercury  biniodide  7^-15  grs. 

tract,  especially  the  nose,  should  be  cor-  lard  1  oz.— M. 

rected,  while  anything  tending  to  cause  • 

congestion  of   the   face,   such   as   tight  Sulphur    preparations,    as    already 

collars    or    stays,    should    carefully    be  stated,  are,  however,   the  most  useful, 

avoided.      Sedentary  intellectual  work,  those  commonly  employed  m  acne  being 

especially   bv    gaslight,    frequently    ag-  prescribed.                                  ^ 

gravates  the'se  cases.  I"  cases  of  average  intensity  derma- 

On  the  supposition  that  a  rheumatic  tologists    frequently    employ    Vlem- 

diathesis  is  a  possible  etiological  factor,  inckx's  solution,  at  first  with  o  parts 

various     alkalies     have     been     recom-  of   water,    then   gradually    making   it 

mended,     especiallv     bicarbonate     of  stronger    until    it    is    used    pure.     It 

.soda  or  the  various  alkaline  waters.  should  be  left  on  several  minutes,  and 

Where    the     face     is     intermittently  followed  by  very  hot  water;  it  may 

congested,    quinine,    ergotine,    bella-  often  be  left  on  overnight  with  advan- 

donna,  digitalis,  and  hamamelis  have  tage. 

been  suggested.    These  may  be  com-  Green  soap  gives  the  best  results  in 

bined  in  a  mixture,  wath  or  without  obstinate  acne  rosacea,  alone  or  when 

the  tincture  of  aconite-root.  Vasocon-  used    in    conjunction    with    sulphur, 

strictor  drugs  have  but  little  influence,  naphthol,  or  salicylic  acid.    It  may  be 

Perchloride   of  iron,   tannin,   ergot,  used  as  in  acne  vulgaris  or  spread  on 

and  tincture  of  hamamelis  are  recom-  a  piece  of  flannel ;  the  latter  is  then  cut 

mended  by  E.  Besnier  and  A.  Doyon.  out  to  fit  the  aft'ected  region,  and  left 

The  following  preparation  is  extolled  on  as  long  as  possible.    It  should  not 

by  Brocq:—  be  left  on  too  long.   AVhen  the  irrita- 


272 


ACNE    ROSACEA    (STELWAGON). 


tion  becomes  too  great,  the  application 
should  cease  and  cooling  preparations, 
such  as  the  following,  be  used : — 
I^  Salicylic   acid    7  grs. 

Zinc  oxide, 

Bismuih  siibnit of  each  30  grs. 

Lycopodinm >2   dr. 

I'aselin    2  drs. 

Lanolin    3  drs. 

Ichthyol  does  not  seem  to  be  as  effi- 
cacious in  acne  rosacea  as  in  some  other 
varieties  of  acne.     (Brocq.) 

Unna  recommends  daily  doses  of  7^ 
grains  of  ichthyol  internally  and  lo- 
tions with  ichthyol  dissolvedin  water, 
washing  with  ichthyol  soap.  Steam 
or  sulphur-water  douches  have  also 
been  used  with  good  results. 

A  solution  of  iodine  in  glycerin,  ap- 
plied twice  daily  during  three  or  four 
days,  is  recommended  by  Kaposi  for 
the  more  severe  forms,  but  it  is  dis- 
figuring and  not  advisable  for  patients 
outside  of  hospital  wards. 

The  commencing  erythema  of  acne 
rosacea,  a  very  troublesome  and  dis- 
figuring complaint,  especially  to  ladies, 
is  removed  by  an  ointment  containing 
10  grains  of  the  iodide  of  cadmium 
in  1  ounce  of  vaselin.  It  should  be 
rubbed  well  into  cheeks  and  nose  at 
night,  and  washed  off  next  morning 
with  hot  water  and  an  overfatted 
soap,  accompanied  by  massage  of  all 
the  afifected  skin.  The  iodide  of  cad- 
mium does  not  stain  the  skin  and  is 
an  excellent  local  stimulant.  If  too 
strong  it  irritates.  H.  S.  Purdon 
(Dublin  Jour,  of  Med.  Sci.,  Sept.  1, 
1903). 

In  a  series  of  cases  of  acne  rosacea 
the  author  succeeded  in  gradually  re- 
moving the  eruption  by  means  of  paint- 
ing with  undiluted  iron  chloride.  The 
applications  were  repeated  every  morn- 
ing and  evening,  and  resulted  in  a  com- 
plete cure.  A  somewhat  solid  crust  is 
apt  to  form  at  the  end  of  four  or 
five  days,  and  the  paintings  should  be 
omitted  until  this  £rust  is  cast  oflf  spon- 
taneously.   When  there  is  much  tension 


the  surface  may  be  covered  with  a  clean 
rag  that  has  been  thickly  spread  with 
Wilson's  salve  or  some  other  suitable 
ointment.  In  the  presence  of  severe 
inflammation  an  ice-bag  may  be  ap- 
plied. As  a  rule,  frequent  interrup- 
tions are  unavoidable,  and  the  treat- 
ment is  therefore  likely  to  last 
about  three  or  four  months,  until  the 
cure  is  .  complete.  Zeissl  (Miinch. 
med.  Woch.,  Nu.  20,  1908). 

Surgical  treatment  in  this  disease  is 
the  most  efficacious.     (Brocq.) 

Electrolysis  is  another  satisfactory 
method.  A  fine  platinum  needle  is  in- 
serted alongside  of  the  vessel,  and,  if 
possible,  into  it,  and  connected  with  the 
negative  pole,  while  the  patient  holds  in 
his  hand  a  cylinder  in  communication 
with  the  positive  pole.  A  large  eschar 
must  be  avoided.     (Hardaway.) 

Electrolysis  of  each  dilated  sebaceous 
follicle  with  a  negative  platinum  needle 
and  a  current  of  from  4  to  6  milliam- 
peres  is  an  effective,  though  tedious, 
measure.  The  needle  should  be  moved 
around  in  the  follicle  in  order  to  thor- 
oughly destroy  it. 

In  the  early  stages  of  acne  hyper- 
trophica,  diet,  a  local  spray  of  sulphur 
lotion,  and  electrolysis  of  the  enlarged 
sebaceous  glands  are  sufficient.  But 
when  hypertrophy  occurs,  with  deform- 
ity and  tumors  of  the  nose,  surgical 
measures  only  are  satisfactory.  The 
author  prefers  thermocautery  to  the 
knife,  and  considers  grafting  undesir- 
able if  this  is  used.  When  the  knife, 
however,  is  used,  skin  grafting  may 
hasten  recovery  and  prevent  cicatricial 
contraction.  Dubreuilh  (Ann.  de  Derm, 
et  de  Syph.,  Nov.,  1903). 

The  ordinary  galvanic  or  faradic 
currents  have  been  recommended  by 
Cheadle  and  Piffard. 

Scarification  was  formerl}^  a  favorite 
method.  The  best  instrument  is  Vidal's 
ordinary  scarificator.  The  skin  is  cut 
obliquely    or    perpendicularly    to    the 


ACNE  ROSACEA  (STELWAGON). 


273 


vessels,  then  slightly  obliquely  across 
these  so  as  to  form  lozenges,  and  as 
near  together  as  possible  (from  1  to 
V/2  mm.  apart),  and  not  deep  enough 
to  penetrate  entirely  through  the  der- 
mis, so  as  to  avoid  cicatrices. 

If  there  arc  only  a   few  large  veins 
visible    at    the    root    of    the    nose,    the 
writer  merely  pierces  each  of  these  with 
a  galvanocautery  needle;  but  if  there 
are  many  he  punctures  the  entire  skin 
of   the   nose    with   points    so    close   to- 
gether that  no  vessel  can  be  missed,  to 
a  depth  of  /2  to  1/2  mm.     The  entire 
skin  soon  sloughs  off,  and  the  resultmg 
raw   surface   is  trimmed   into   shape   as 
necessary  by  the   cautery,   and  dressed 
with   an   antiseptic  powder   (bismuth, 
dermaton.     The   skin  heals  in  about 
twelve    days.     This   method  has    given 
better     results     than     operations     with 
the    knife    or    electrolysis;      Bolebaum 
(Miinch.  med.  Woch.,  No.  52,  1904). 


An  hour  afterward  the  part  is  washed 
with  a  corrosive  sublimate  solution, 
1 :  1000 ;  then  in  the  evening  or  the  fol- 
lowing'day  compresses  dipped  into 
an  ammonium  hydrochlorate  solution, 
1 :  100,  or  corrosive  sublimate,  1 :  oOO, 
are  applied.  If  too  strong,  warm  water 
is  to  be  added.  If  the  reaction  is  too 
violent,  starch  poultices,  bland  poma- 
tums, or  zinc  oxide  plasters  can  be 
employed. 

The  treatment  should  be  renewed  in 
from  five  to  eight  days.  Amelioration 
will  occur  in  from  eight  to  ten  sessions, 
and  marked  improvement  in  from 
fifteen  to  twenty-five  sessions. 

Scarifying  should  be  begun  in  the 
lower  part  of  the  region  to  be  operated 
upon,  in  order  not  to  be  troubled  by  the 
blood  covering  the  surface.  (E.  Bes- 
nier,  A.  Doyon.) 

In  the  early  stage  of  hypertrophic 
acne  the  scarification  must  be  made 
deeper,  and  in  many  cases  it  is  essential 
to  also  cauterize  the  glands  deeply 


In  the  advanced  hypertrophic  form 
direct  removal  with  the  knife  is  the 
best  procedure.     (Rrocq.) 

In  hypertrophic  acne  of  the  nose  the 
writer     recommends     ablation     with 
knife  and  scissors  under  cocaine  anes- 
thesia.    The  disease  is  really  an  ade- 
noma of  the  sebaceous  glands  of  the 
nose,  and  in   spite  of  appearances  is 
confined  to  the  skin  and  its  annexes, 
and  always  ceases  at  the  margins  of 
the    nostrils.     The    tumor   is    divided 
vertically  into  two  halves;  each  half  is 
separated  from  the  margin  of  the  nos- 
trils, and  an  incision  is  made  outside 
beyond  the  limits  of  the  growth.    The 
two  halves  are  then  successively  re- 
moved en  bloc  or  by  repeated  sections. 
The  bleeding  is  abundant,  but  is,  as  a 
rule,  easily  controlled  by  pressure  or 
by    forceps.       Care     must    be    taken 
not    to    injure    the    fibrocartilaginous 
framework  of  the  nose.     It  is  better 
not  to  graft  the  wound  with  skin  or 
do  any  autoplaitic  oper.tion.     In  five 
or  six  weeks  the  skin  has  g-own  over 
and  cQvered  the  wo  md.    If  the  wound 
is  not  being  covered  quickly  enough, 
grafts  may  be  applied  when  granula- 
Sons  are  abundant.     Mcrestin  (Arch, 
gen.  de  med.,  vol.  cxcii,  p.  2330,  1903). 


Hypodermic    injections    of    alcohol 

have  recently  been  recommended. 
Phototherapy  has  likewise  given  sat- 
isfactory results ;  both  high-frequency 
current  and  the  X-ray  are  of  value  m 
some  cases. 

The  light  treatment  of  this  form  of 
acne  should  be  included  among  the  rec- 
ognized therapeutical  measures.  It 
brings  about  a  cure  more  rapidly  than 
chemical  means  (salves,  etc.),  and  is 
more  quickly  efficacious  than  it  is.  in 
tuberculous  or  erythematous  lupus.  In 
most  of  the  cases  the  cure  remained 
perfect;  in  others  it  became  so  when 
combined  with  external  treatment,  and 
with  the  necessary  attention  to  the  vis- 
ceral disturbances,  especially  of  the 
gastrointestinal  tract.  Phototherapy  is 
specially  applicable  to  rosaceous  acne 
of  the  nose,  where  the  lesions  are  often 
1—18 


274 


ACOIX. 


ACOXITE    (SAJOUS). 


much  deeper  than  on  the  cheeks ;  but 
if  the  action  of  the  light  is  not  promptly 
efificacious,  scarification  may  be  used  at 
the  same  time.  M.  Leredde  (Jour,  des 
praticiens,  April  18,  1903). 

Henry  \\'.  Stelwagox, 

Philadelphia. 

ACNE  VACCINE.  See  Bac- 
terial Vaccixes. 

ACOrN,  a  synthetic  compound  used  as 
local  anesthetic,  especially  in  dental  and 
ophthalmic  practice.  It  is  designated  as 
alkyloxyphenylguanidin  and  occurs  as  a 
white  crystalline  powder,  readity  soluble  in 
pure  cold  water  to  the  extent  of  6  per  cent., 
and  in  alcohol. 

A  1 :  200  aqueous  solution  injected  under 
the  skin  causes  a  local  anesthesia  lasting 
about  one  hour.  Acoin  presents  the  draw- 
back, however,  of  being  quite  unstable,  while 
producing  greater  irritation  than  cocaine, 
and  is  liable  to  produce  necrosis.  S. 

ACONITE.— The  preparations  of 
aconite  usually  employed  are  obtained 
from  the  root  of  the  Aconitum  napelhis 
(monkshood,  wolfsbane),  a  conical 
tuber  greatly  resembling  horse-radish. 
This  resemblance  has  caused  many 
deaths.  Aconite-r-oot  is,  however, 
brown  in  color,  and  when  scraped  does 
not  emit  the  pungent  odor  peculiar  to 
horse-radish.  Again,  instead  of  irri- 
tating the  palate,  as  does  horse-radish, 
aconite-root,  when  masticated,  soon 
produces  in  the  mouth  a  sense  of 
warmth  and  tingling,  soon  followed  by 
local  numbness  varying  in  duration  ac- 
cording to  the  length  of  time  the 
mucous  membrane  is  exposed  to  the  ef- 
fects of  the  drug.  Aconite  owes  its 
activity  mainly  to  the  alkaloid  aconitine, 
of  which  the  dried  root  is  officially  re- 
quired to  contain  0.5  per  cent. 

PREPARATIONS  AND  DOSE.— 
Aconite  in  substance  is  not  employed, 
and  the  preparations  made  with  the 
leaves  are  no  longer  official. 


The  tincture  (tinctiira  aconiti,  1905 
U.  S.  P.)  is  no  longer  stronger  than 
the  English  or  French  tinctures.  It  is 
a  10  per  cent,  tincture,  i.e.,  it  contains 
10  Gm.  of  the  drug  in  100  c.c.  Dose, 
3  to  10  minims,  every  three  hours.  Its 
effects  should  be  closely  vratched, 
especially  in  anemic  and  corpulent  indi- 
viduals and  in  those  addicted  to  alcohol. 
In  prescribing  the  tincture,  the  1905 
U.  S.  P.  should  be  specified,  to  avoid 
accidents. 

The  fluidextract  (fluidc.rtractum  aco- 
niti, U.  S.  P.),  ^  to  1  minim. 

The  alkaloid  aconitine  {aconitina, 
U.  S.  P.),  %oo  grain  to  %oo  grain  (0.1 
to  0.2  mg.),  occurs  in  the  form  of  col- 
orless tabular  crystals  slightly  soluble 
in  water^  but  soluble  in  alcohol,  ether, 
and  chloroform. 

Aconitine  is  a  very  active  poison  and 
causes  the  responsibility  of  the  physi- 
cian to  be  involved  to  a  greater  degree 
than  any  other  toxic.  Its  activity  is 
markedly  increased  when  it  is  adminis- 
tered hypodermically,  and  the  injections 
are  very  painful.  These  facts  and  the 
variations  in  strength  of  the  various 
aconitines  on  the  market  have  militated 
against  its  use,  and  it  is  best  to  utilize 
the  other  preparations,  both  of  which 
owe  their  activity  to  aconitine. 

MODES  OF  ADMINISTRATION. 
— Internally  aconite  is  usually  better 
given  in  small  and  frequently  repeated 
doses  than  in  large  doses  at  longer  in- 
tervals. Thus  the  tincture  may  be 
given  in  1  minim  doses  every  hour  until 
the  desired  effect  has  appeared  or  until 
distinct  depression  of  the  circulation 
indicates  cessation  of  the  drug.  Aconite 
should  be  administered  well  diluted. 
In  fever  a  dram  of  a  mixture  of  10 
minims  of  the  tincture  in  4  ounces  of 
Avater  may  be  given  every  fifteen  or 
twenty  minutes.  For  the  relief  of  pain, 


ACONITE    (SAJOUS). 


275 


5  minims  may  be  administered  as  the 
first  dose,  smaller  ones  being  then  given 
at  short  intervals.  For  cardiac  over- 
activity, doses  of  2  to  5  minims  (0.12 
to  0.30  c.c. )  may  be  given  thrice  daily. 
When  aconite  is  used  over  a  long 
period,  a  gradual  increase  in  its  action 
is  observed.  Even  where  indicated, 
aconite  should  not  be  given  freely  with 
the  intention  of  producing  powerful  ef- 
fects, as  its  action  in  large  doses  is 
sometimes  unexpectedly  severe. 

Aconitine  may  be  administered  inter- 
nally in  granules,  in  tablets  or  tablet 
triturates  such  as  are  official  in  the 
N.  F.,  or  in  solution  in  v^•ater  (1  in 
3200).  Tison  has  used  aconitine  nitrate 
dissolved  in  a  mixture  of  distilled 
water,  alcohol  and  glycerin,  1  minim  of 
the  solution  containing  ^^3200  grain  of 
the  salt.  As  stated  above  the  alkaloid 
should  be  employed  with  great  caution, 
as  individual  intolerance  of  it  has  been 
repeatedly  observed;  a  third  dose  of 
M.30  grain  (0.5  mg.)  has  been  known 
to  cause  death  (Lepine).  Dose  of 
yi300  grain  (0.1  mg.)  may  be  given 
every  two  or  three  hours,  the  drug 
being  stopped  when  the  first  signs  of 
toxic  action  appear;  these  are,  accord- 
ing to  Gubler :  prickling  of  the  tongue, 
a  sensation  of  shrinkage  in  the  face, 
and  loss  of  elasticity  of  the  muscular 
openings  in  this  region.  These  are  fol- 
lowed by  general  numbness  and  chilli- 
ness. A  total  amount  of  %oo  to  %5 
grain  (0.66  to  1.0  mg.)  in  twenty- 
four  hours  may  be  considered  the  limit 
of  safety.  Dujardin-Beaumetz  advised 
never  to  give  aconitine  unless  its  effects 
can  be  carefully  watched. 

LOCAL  USE.— Aconite  is  used 
locally  in  neuralgia  and  skin  affections, 
the  tincture  sometimes  diluted  with 
alcohol,  or  the  linimentum  aconiti  et 
chloroformi    of    the    N.    F.     (fluidext. 


aconit.  4.5,  chloroform  12.5,  in  alcohol 
100),  being  applied.  The  alkaloid  is 
also  sometimes  used  in  a  2  per  cent, 
ointment  or  in  the  oleatum  aconitin?e, 
N.  F.  (2  per  cent.),  but  should  never 
be  applied  to  abraded  areas.  Undiluted 
aconitine  is  absorbed  through  both 
mucous  membranes  and  skin  to  a  con- 
siderable extent. 

Subcutaneous  injections  of  aconitine 
have  been  given  for  neuralgia,  but  the 
pain  caused  and  the  danger  from 
prompt  toxic  effects  are  marked  disad- 
vantages. 

INCOMPATIBILITIES.— The  al- 
kaloid aconitine  in  solution  (1  to  3200 
being  saturated)  is  incompatible  with 
tannic  acid,  gallic  acid,  mercurials,  and 
Lugol's  solution ;  aconitine  nitrate  is 
precipitated  as  the  alkaloid  by  alkalies. 
AmOTg  the  physiological  incompatibili- 
ties of  aconite  may  be  mentioned  digi- 
talis, atropine,  strychnine,  strophanthus, 
ammonia  and  alcohol. 

CONTRAINDICATIONS.  —  By 
reason  of  its  depressant  action  aco- 
nite is  contraindicated  in  all  cases  in 
which  prostration  exists  or.  threatens. 
If  the  respiration  is  embarrassed;  if  the 
heart  is  in  asystole ;  if  the  patient  is  de- 
pressed, recourse  must  be  had  to  tonics 
and  stimulants.  In  bronchopneumonia, 
pneumonia  after  the  primary  stage, 
typhoid  fever,  phthisis,  valvular  affec- 
tions of  the  heart,  and  in  all  cases  of 
collapse  occurring  in  acute  infectious 
diseases,  aconite  is  particularly  contra- 
indicated.  In  no  case  Avhere  the  heart 
is  weakened  or  degenerated  should  the 
use  of  aconite  be  considered.  Old  age 
contraindicates  its  use  to  lower  the 
blood-pressure  in  nephritis. 

PHYSIOLOGICAL  ACTION.— 
AVithin  half  an  hour  after  its  adminis- 
tration, aconite  commences  to  affect 
the  general  system,  slowing  and  weak- 


276 


ACONITE    (SAJOUS). 


ening  the  heart's  action,  lowering  arte- 
rial tension,  increasing  the  action  of  the 
skin  and  kidneys,  and  producing  more 
or  less  muscular  weakness  in  propor- 
tion to  the  amount  taken.  It  causes  a 
tingling  sensation  in  the  lips,  extremi- 
ties, and,  perhaps,  the  whole  body;  it 
diminishes  the  rapidity  and  depth  of 
the  respiration,  and  causes  disorders  of 
vision,  vertigo,  and  loss  of  tactile  sensi- 
bility and  sense  of  pain.  The  effects  of 
a  therapeutic  dose  last  three  or  four 
hours. 

Aconite,  when  administered  in  suffi- 
cient dose,  is  a  powerful  depressant  of 
the  sensory  nerve ;  some  have  believed 
that  the  stage  of  nerve  paralysis  is 
preceded  by  one  of  nerve  stimulation, 
but  Wood  considers  this  doubtful.  The 
drug  paralyzes  first  the  sensory  end- 
organs,  next  the  nerve-trunks,  and 
finally  the  centers  of  sensation  in  the 
cord.  The  reflexes  are  correspondingly 
impaired.  The  power  of  voluntary 
movement,  which  continues  after  the 
cessation  of  the  reflex  functions,  is 
finally  lost,  owing  to  the  later  action  on 
the  motor  centers  of  the  cord,  and  sub- 
sequently on  the  nerve-trunks.  The 
brain  is  practically  unaffected  by 
aconite. 

Laborde  and  Duquesnel  state  that 
aconitine  in  therapeutic  doses  has  a 
particular  effect  in  modifying  special 
sensibility  in  the  area  of  the  trigeminal ; 
they  believe  this  effect  to  be  exerted  on 
the  bulbar  receptive  nuclei  of  the  nerve. 
According  to  Cushny,  the  subjective 
sensory  phenomena  resulting  from  the 
use  of  aconitine  are  due  to  a  marked 
primary  stimulation  and  secondary  de- 
pression of  the  sensory  end-organs, 
tingling  and  warmth  locally  being  fol- 
lowed by  numbness  when  the  drug  is 
applied  to  the  skin  or  taken  by  the 
mouth. 


Pyraconitine,  obtained  from  aconitine 
by  heating  to  separate  a  molecule  of 
acetic  acid,  causes  no  tingling  of  the 
lips  or  tongue.  It  causes  slowing  of  the 
heart,  partly  from  vagus  irritation, 
partly  from  depression  in  function  of 
intrinsic  rhythmical  and  motor  mechan- 
isms. After  its  administration  activity 
of  respiration  is  reduced  (by  central  de- 
pression) to  a  degree  incompatible  with 
life.  Neither  muscular  nor  intramus- 
cular nervous  tissue  is  strongly  influ- 
enced by  pyraconitine,  but  the  spinal . 
cord  is  impaired  in  its  reflex  function, 
and  there  is  a  curious  condition  of  ex- 
aggerated motilit3^  Theodore  Cash  and 
W.  K.  Dunstan  (Brit.  Med.  Jour.,  Aug. 
17,  1901). 

The  physiological  actions  of  aconite 
and  veratrum  viride  are  so  similar  that 
what  is  to  be  said  of  aconite  can  be 
applied  with  equal  force  to  veratrum. 
The  physiological  action  of  aconite  may 
-be  stated  thus  :  Primary  action  :  stimu- 
lation of  the  peripheral  nerve-endings; 
stimulation  of  the  vasomotor  mechan- 
ism; powerful  stimulation  of  the  res- 
piratory center.  Secondary  action : 
paralysis  of  the  overstimulated  periph- 
eral nerve-endings ;  pronounced  depres- 
sion of  the  heart;  lowering  of  the 
blood-pressure;  reduction  of  tempera- 
ture. W.  B.  Hill  (Jour.  Amer.  Med. 
Assoc,  Dec.  12,  1903). 

A\'hen  aconite  is  applied  directly  to 
the  heart,  the  number  and  force  of  the 
beats  are  lessened,  and  its  action  is 
finally  arrested  in  diastole.  It  lowers 
the  blood-pressure  and  pulse-rate  when 
given  internally  by  a  direct  depressant 
action  on  the  heart  itself,  and  also  by 
stimulating  the  cardioinhibitory  center. 
Laborde  found,  however,  that  the  con- 
tractility of  the  cardiac  muscle-fiber 
itself  was  not  directly  modified  by 
aconitine. 

Hare  has  called  attention  to  the 
fact  that  the  fall  in  pulse-rate  from 
poisonous  doses  is  sometimes  preceded 
by  a  quickening  due  to  a  condition  of 
weakness  and  abortive  cardiac  action. 


ACONITE    (SAJOUS). 


277 


The  stage  of  low  pulse-rate  is  also  fol- 
lowed by  one  in  which  the  pulse  is  fre- 
quent and  irregular.  Upon  the  vaso- 
motor center  aconite  is  believed  by 
Cash  and  Dunstan  to  have  a  late  depres- 
sant effect.  It  also  causes  slowing  of 
the  respiration,  with  lengthening  of  the 
expiratory  period,  by  depressing  power- 
fully the  respiratory  center.  According 
to  some  observers,  small  amounts  of 
the  drug  produce,  instead,  stimulation 
of  the  respiratory  function,  while 
Cushny  is  of  the  opinion  that  aconitine 
has  a  primary  exciting  effect  on  most 
of  the  medullary  centers — vagal,  vaso- 
motor, respiratory — as  well  as  the 
spinal  motor  centers. 

Aconite  reduces  the  temperature  both 
in  health  and  in  febrile  conditions, 
probably  through  an  action  on  the 
nervous  heat-regulating  mechanism, 
and  by  the  circulatory  depression  it 
causes.  It  also  increases  the  action  of 
the  skin,  kidneys,  and  salivary  glands. 
Increase  of  the  gastrointestinal  and 
biliary  secretions  is  stated  to  have  oc- 
curred.    (Schrofif,  Rabuteau.) 

[Personal  researches  (see  "Internal  Secre- 
tions," p.  1347)  have  shown  that  the  physio- 
logical effects  of  aconite  are  due  to  its  de- 
pressing action  on  the  sympathetic  center, 
which,  as  I  have  pointed  out  (ibid.,  p.  1185), 
governs  the  caliber  of  all  arterioles.  These 
vessels  being  thus  caused  to  relax,  more 
blood  is  admitted  into  all  capillaries,  and 
passive  hyperemia  of  all  tissues  is  produced. 
If  this  is  slight  only  a  feeling  of  warmth  is 
experienced;  if  it  is  marked  the  cutaneous 
sensory  nervous  elements  are  sufficiently  con- 
gested to  awaken  sensations  of  prickling  and 
tingling. 

If  the  dose  is  large  the  dilatation  of  the 
arterioles  is  sufficient  to  reduce  markedly  the 
vis  a  tergo  motion  of  the  blood  in  the  tis- 
sues, and,  the  rate  of  metabolism  being 
slowed,  the  functions  of  the  tissues  are  in- 
hibited; hence  the  lowered  temperature,  the 
numbness,  and,  if  the  dose  is  large  enough, 
the  paralysis.     C.  E.  de  M.  S.] 


MODE     OF    ELIMINATION.— 

iVconite  is  excreted  mainly  by  the  uri- 
nary organs,  though  it  has  also  been  de- 
tected in  small  amounts  in  the  saliva 
and  the  bile. 

ACONITE  POISONING.  — The 
symptoms  following  the  ingestion  of  a 
poisonous  dose  usually  show  them- 
selves after  a  few  minutes.  The 
characteristic  tingling,  prickling,  and 
subsequent  numbness  already  mentioned 
rapidly  extend  from  the  mouth  and 
fauces  to  the  face,  thence  to  the  body 
and  extremities.  Great  prostration  and 
muscular  impotency  follow.  Speaking 
requires  marked  effort.  The  skin  be- 
comes cold  and  clammy,  the  perspira- 
tion covering  the  surface,  and  the 
tissues  communicating  to  the  hand  an 
icy  coldness.  Muscular  pains  may  be 
present  in  the  early  stages,  especially  in 
the  face.  There  is  often  experienced 
marked  epigastric  pain  with  nausea  and 
vomiting._  Later  on  the  nausea  ceases, 
owing  to  paralysis  of  the  stomach  walls. 

The  heart-beats  are  greatly  reduced 
in  number  and  power.  The  pulse  is 
usually  irregular,  compressible,  slow, 
and  so  weak,  at  times,  as  hardly  to  be 
palpable;  in  the  advanced  stages,  how- 
ever, it  becomes  abnormally  frequent. 
The  breathing  is  labored,  irregular,  and 
shallow,  the  number  of  respirations 
being  at  first  decreased,  then  increased. 
Cyanosis  may  appear.  The  tempera- 
ture is  lowered,  sometimes  considerably. 

The  pupils  may  become  dilated  or 
remain  of  normal  size  and  react  equally ; 
occasionally  they  are  contracted.  Ac- 
cording to  Manquat,  they  undergo  fre- 
quent variations  in  size  at  first,  then 
dilate.  The  eyes  may  protrude  or  be 
shrunken ;  therefore  they  afford  no  dif- 
ferential information  as  to  the  nature 
of  the  drug  used. 

The  mind  is  usually  clear,  and  the 


278 


ACONITE    (SAjOUS). 


patient  calm,  though  apprehensive  of 
impending  death.  Disturbances  of 
vision  (diplopia,  amblyopia)  and  of 
hearing  (tinnitus,  deafness),  as  well 
as  vertigo,  are  frequently  complained 
of.  Occasionally  epileptoid  convulsions 
occur.  Spasmodic  purging,  vi^ith  rectal 
tenesmus  and  bloody  stools,  is  occa- 
sionally present. 

Aconite  causes  paralysis  of  respira- 
tion and  circulation,  death  being  due  to 
sudden  arrest  of  the  heart  in  diastole. 

[These  toxic  phenomena  are  readily  ac- 
counted for  by  the  interpretation  of  the 
action  of  aconite  I  have  submitted  above. 
The  inhibition  of  function  due  to  the  dilated 
arterioles  and  the  resulting  delay  in  the 
arterial  circulation  in  the  muscles  explain, 
when  sufficiently  marked,  the  great  prostra- 
tion, the  muscular  impotence,  the  cold  and 
clammy  skin,  the  cold  sweats,  the  relaxation 
of  the  stomach  walls,  the  slow  compressible 
pulse  (owing  to  weakness  of  the  cardiac 
muscle),  etc. 

The  vascular  interference  with  the  pro- 
pulsion of  blood  to  the  air-cells  and  the 
weakness  of  the  respiratory  thoracic  mus- 
cles account  for  the  intense  dyspnea  and 
the  shallow  breathing.  The  cause  of  the 
failure  of  respiration  is  obvious  under  these 
conditions,  while  the  cardiac  arrest  in  diastole 
points  to  muscular  impotence  of  the  myo- 
cardium in  common  with  all  other  muscles. 
C.  E.  DE  M.  S.] 

Cases  of  criminal  poisoning  by  aconite 
are    rare.      In    the    Condon    case?    of 
Springfield,   Mass.,  the  defendant  pur- 
'  chased   a  two-ounce  bottle   of  tincture 

of  aconite,  one-half  of  which  was 
placed  in  a  pint  bottle  of  port  wine 
and  sent  to  the'  person  whose  life  was 
attempted,  and  who  drank  nearly  one- 
half  of  the  wine.  The  immediate  effect 
was  dizziness,  inability  to  move,  and  a 
peculiar  creeping  sensation  in  the  mus- 
cles. The  vision  became  obscure.  Life 
was  only  saved  by  three  hours  of  un- 
tiring efforts.  W.  S.  Magill  (Med. 
News,   May  31,   1902). 

Case  of  aconite  poisoning  in  which 
the  patient's  condition  became  criti- 
cal; the  pulse  varied  from  130  to  140, 


was  extremely  feeble,  and  at  times 
was  felt  with  difficulty;  the  extremi- 
ties were  cold  and  the  lips  blue,  but 
the  face  retained  a  dusky  flush;  the 
convulsive  movements  were  increas- 
ing. It  seemed  clear  that  the  aconite 
was  causing  extreme  depression  of 
the  heart.  The  writer  gave  10  min- 
ims of  liquid  strychnine  hypodermic- 
ally  and  injected  8  ounces  of  hot, 
strong  coffee  slowly  into  the  rectum, 
applied  hot  bottles,  and  wrapped  him 
up  in  hot  blankets.  After  about  an 
hour,  during  which  his  condition  gave 
rise  to  great  anxiety,  he  began  to 
rally,  became  semiconscious,  and 
rambled  in  his  speech;  the  convulsive 
movements  gradually  ceased  and  the 
pulse  became  fuller  and  stronger  and 
the  body  surface  warm.  At  3  a.m. 
his  condition  had  so  far  improved 
that  he  was  left  in  charge  of  a  nurse. 
The  next  morning  he  was  better,  the 
pulse,  though  still  rapid,  was  of  good 
quality,  and,  beyond  being  somewhat 
dazed  and  shaken,  he  expressed  him- 
self as  feeling  very  well,  and  refused 
to  believe  that  anything  serious  had 
happened.  For  the  next  few  days, 
during  which  his  only  complaint  was 
of  numbness  and  tingling  in  the  fin- 
gers, he  was  kept  at  rest  in  bed  until 
his  circulation  had  resumed  its  usual 
state,  which  showed  itself  to  be  one 
of  high  tension,  bounding  vessels,  and 
hypertrophied  heart.  His  recollection 
gradually  came  back  of  having  no- 
ticed a  pungent  taste  with  tingling  of 
the  mouth  after  taking  his  medicine, 
but  he  thought  nothing  of  it  at  the 
time,  nor  did  it  occur  to  him  that  he 
had  made  any  mistake,  i.e.j  that  of 
taking  a  tablespoonful  of  a  liniment 
containing  aconite.  The  quantities 
contained  in  the  tablespoonful  dose 
of  the  liniment  were  40  minims  each 
of  lin.  aconiti,  lin.  belladonnse,  lin. 
chloroformi,  and  tinct.  capsici,  with 
80  minims  of  ol.  gaultherise.  Taking 
the  recognized  standard  for  aconite 
root  as  containing  0.5  per  cent,  of 
aconitine,  40  minims  of  lin.  aconiti 
would  be  equivalent  to  0.132  grain 
aconitine — i.e.,  about  ys  grain,  or  31 
times   the    maximum   dose,   which   is 


ACONITE    (SAJOUS). 


279 


given  as  %r.o  grain.     W.   Edgeconi1)c 
(Lancet,  Oct.  29,  1910). 

Case  of  aconite  poisoning  in  a  woman 
aged  45  years,  a  multipara,  wlio  had 
suffered  from  rheumatism,  shortness  of 
breath,  and  swollen  feet.  She  drank  by 
mistake  about  3  ounces  of  a  liniment. 
At  once  she  recognized  her  mistake  and 
experienced  a  hot  tingling  in  the  mouth, 
then  numbness,  giddiness,  gastric  pains, 
and  soon  thereafter  followed  by  col- 
lapse. A  druggist  gave  ipecacuanha 
wine  and  a  strong  emetic.  Sickness 
continued,  and  a  violent  attack  of  clonic 
convulsions  supervened. 

The  medical  man  called  in  found  the 
patient  speechless,  cold,  pale,  skin  moist, 
pulseless,  respirations  very  faint  and 
irregular,  and  the  pupils  dilated  and 
insensitive,  but  no  ptosis.  The  tem- 
perature was  96.6°  F.  Terrible  gastric 
and  abdominal  pains  and  violent  irri- 
tation and  prickling  of  the  skin  were 
succeeded  by  numbness.  Three  times 
after  attacks  of  clonic  convulsions  she 
appeared  dead,  but  when  they  ceased 
the  mind  was  clear  and  unaffected.  As 
a  cardiac  depressant,  ipecacuanha  had 
been  given;  a  mustard  emetic  was  now- 
administered  to  save  the  enfeebled 
heart.  The  head  was  kept  low,  the 
feet  were  raised,  a  sinapism  was  placed 
over  the  heart,  and  hot  bottles  and 
flannels  were  applied  to  the  lower  ex- 
tremities and  abdomen.  Strychnine 
and  digitalis  were  given  hypodermic- 
ally,  and  brandy  was  injected  per  rec- 
tum. Artificial  respiration  was  un- 
ceasingly kept  up.  After  an  anxious 
six  hours  the  breathing  became  stron- 
ger,' an  irregular,  intermitting  pulse 
could  be  felt  at  the  wrist,  while  the 
body  warmth  slowly  returned.  A  little 
coffee  and  brandy  were  swallowed  and 
retained.  The  crisis  passed,  and  she 
recovered.  The  quantity  of  aconite 
taken  may  be  roughly  estimated  as 
suificient  to  kill  6  persons.  Inglis 
(Lancet,  Jan.  21,  1911). 

Death  occurs  in  from  one-half  to  five 
and  half  hours,  the  average  being,  ac- 
cording to  Reichert,  three  and  one-third 
hours. 


The  symptoms  resulting  from  a 
poisonous  dose  of  the  alkaloid  aconi- 
tine  are  the  same  as  mentioned  above, 
but  they  occur  more  rapidly ;  hypoder- 
mically  administered,  aconitine  may 
cause  death  in  less  than  a  minute. 

Treatment  of  Aconite  Poisoning. — 
Deatli  in  these  cases  usually  follows 
exertion  by  the  patient.  He  should, 
therefore,  be  kept  perfectly  motionless 
in  the  recumbent  position,  even  during 
emesis,  his  head  being  slightly  turned 
and  the  dejections  received  on  a  towel. 
An  important  feature  of  the  treatment 
is  to  keep  the  patient  as  warm  as  pos- 
sible by  means  of  warm  blankets  and 
hot-vv^ater  bottles,  taking  care  not  to 
place  the  latter  against  the  skin.  The 
head  should  also  be  kept  warm.  If  the 
patient  is  seen  early  the  stomach-tube 
should  be  used  at  once  to  empty  the 
stomach.  "If  no  stomach-tube  be  at 
hand,  apomorphine,  ^(2  to  %  grain, 
should  be.  administered  hypodermically, 
or  some  other  active  emetic,  such  as 
zinc  sulphate,  15  to  30  grains^  be  given 
by  the  mouth. 

[From  my  viewpoint,  apomorphine  (q.  v.) 
is  contraindicated  as  an  emetic  in  these  cases, 
since  it  causes  emesis  precisely  in  the  same 
way  as  aconite  does  it,  i.e.,  by  depressing 
the  sympathetic  center.  The  emetics  which 
are  indicated  when  there  is  any  degree  of 
depression  are,  mustard,  zinc  sulphate, 
etc.     C.  E.  DE  M.  S.] 

Digitalis,  sulphate  of  strychnine,  and 
belladonna  are  the  most  effective  rem- 
edies, but  ether  and  ammonia  should 
first  be  employed,  owing  to  their  great 
diffusibility.  All  these  remedies  should 
be  used  hypodermically,  the  stomach 
being  unable  to  perform  its  functions. 
A  dram  of  ether,  ammonia,  brandy,  or 
whisky  should  at  once  be  injected,  and, 
after  a  few  minutes,  tincture  of  digi- 
talis, 15  minims;  strychnine  sulphate, 
%o  grain;  or  tincture  of  belladonna,  10 


280 


ACONITE    (SAJOUS). 


minims,  according  to  what  the  practi- 
tioner may  have.  Atropine  has  been 
recommended  as  the  most  powerful 
antagonist  to  the  depressing  effects  of 
aconite  on  the  circulation  and  respira- 
tion. The  dosage  should  be  regulated 
so  as  to  reach  the  point  of  physiological 
action  by  frequently  repeated  doses. 
Nitrite  of  amyl  may  be  given  by  in- 
halation, and  warm,  very  strong  cof- 
fee be  injected  into  the  rectum. 

[Nitrite  of  amyl,  according  to  my  views 
(see  "Internal  Secretions,"  p.  1350),  is  also  a 
paralyzant  of  the  sympathetic  center,  and 
should  not  be  used  any  more  than  any  other 
nitrite. 

Belladonna  I  regard  as  the  direct  antidote 
of  aconite,  since,  as  stated  (1907)  in  "Inter- 
nal Secretions,"  p.  1210,  it  stimulates  "(1)  the 
test-organ  (anterior  pituitary)  and  through 
it  the  adrenal  center,  and  (2)  the  sympathetic 
center  (posterior),  which  governs  the  tonus 
and  propulsive  activity  of  the  arterioles." 
In  other  words,  it  counteracts  precisely  the 
paralysis  of  the  sympathetic  center  caused 
by  aconite.  This  proves  true  practically. 
C.  E.  DE  M.  S.] 

Case  illustrating  the  physiologic 
antagonism  between  aconite  and  bella- 
donna. The  patient  had  taken  by  mis- 
take half  an  ounce  of  a  liniment  com- 
posed of  chloroform,  aconite,  and  bel- 
ladonna. This  means  53.3  grains  of 
aconite  root,  which  represents  y^  grain 
of  aconitine,  of  which  %6  grain  has 
been  known  to  be  fatal.  He  also  swal- 
lowed 40  minims  of  fluidextract  of 
belladonna  (B.  P.),  which  is  equal  to 
0.3  grain  of  the  total  alkaloids.  This 
would  represent,  approximately,  thirty 
times  the  official  dose  of  atropine.  Of 
chloroform  he  took  40  minims,  about 
eight  times  the  official  dose.  The  in- 
terest in  the  case  lies  in  the  fact  that 
the  lethal  effect  of  a  large  dose  of 
aconite  was  abolished  by  the  simultane- 
ous action  of  a  large  dose  of  bella- 
donna. Muscular  weakness,  numbness 
of  the  extremities,  and  tendency  to 
complete  collapse  were  the  only  purely 
aconite  symptoms  observed.  Saliva- 
tion, which  is  usually  present  in  aconite 


poisoning,  was  absent,  and  the  usually 
contracted  pupil  was  overcome  by  the 
action  of  the  atropine.  Finally,  the  in- 
tensely depressant  action  of  aconite  on 
the  central  nervous  system  was  coun- 
teracted by  the  stimulating  influence  of 
the  belladonna.  The  obvious  lesson  to 
be  drawn  from  the  case  is  the  great 
value  which  should  be  attached  to 
hypodermic  injections  of  atropine  in 
aconite  poisoning.  Speirs  (Brit.  Med. 
Jour.,  Aug.   15,   1908). 

Tannic  acid  is  useful  as  an  antidote. 
Wood  recommends  that  it  be  followed 
by  an  emetic  and  cathartic  to  avoid  the 
effects  of  resolution  of  the  poison  by 
the  digestive  fluids. 

If  the  patient  is  seen  when  the  stage 
of  depression  has  begun  through  ab- 
sorption of  the  poison,  the  stomach- 
pump,  gently  used,  is  alone  permis- 
sible, emetics  at  this  stage  being  liable 
to  cause  arrest  of  the  heart's  action. 
Tincture  of  digitalis,  in  20-minim 
doses,  should  be  injected  hypodermi- 
cally  and  repeated  as  required,  besides 
the  other  measures  indicated.  Fric- 
tions under  cover,  the  rubbing  being 
directed  over  the  heart,  serve  a  useful 
purpose.  Artificial  respiration  is  of 
marked  benefit  and  should  be  used  per- 
sistently as  long  as  any  indication 
exists. 

Since  the  strength  of  the  tincture  has 
been  decreased  (U.  S.  P.  1905),  the 
cases  of  poisoning  have  been  greatly 
reduced,  and  are  seldom  in  fact  met 
with  in  hterature.  Hence  the  fact  that 
practically  all  the  instances  recorded 
in  these  pages  antedate  the  year  of  the 
last  Pharmacopoeia.    - 

Twenty  cases,  6  of  which  were  fatal, 
found  in  the  literature  of  ten  years  : — 
Case  1.  Tincture,  7  drams.  Recov- 
ery. Emetics;  morphine,  %  grain;  fluid- 
extract  of  digitalis,  6  drops;  strych- 
nine sulphate,  i/ieo  grain;  brandy,  1 
ounce;  all  hypodermically.  By  the 
mouth,  2  gallons  of  warm  water;  fluid- 


ACONITE    (SAJOUS). 


281 


extract  of  digitalis,  20  drops;  coffee, 
11  pints;  whisky,  3  pints;  extract  of 
nux  vomica,  y^  fluidram;  port  wine,  V> 
pint.  P.  F.  Brick  (Jour.  Amer.  Med. 
Assoc,  vol.  viii,  p.  567,  1887). 

Case  2.  About  8  drops  of  concen- 
trated fluidextract.  Recovery.  Emet- 
ics, coffee,  whisky  (dessertspoonful). 
Heat.  Friction  and  sinapism.  T.  H. 
P.  Baker  (Amer.  Pract.  and  News, 
vol.  iv,  N.  S.,  p.  122,  1887). 

Case  3.  Fleming's  tincture,  1^ 
ounces.  Recovery.  Emetics,  brandy, 
ether,  digitalis,  ammonia  carbonate. 
Amy!  nitrite  and  warmth.  C.  C.  Brad- 
ley (N.  Y.  Med.  Record,  vol.  xxxii,  p. 
155,  1887). 

Case  4.  Tincture,  ><  ounce.  Recov- 
ery. Brandy  by  mouth  and  hypoder- 
mically.  Ether.  One  quart  of  cold, 
black  coffee.  Heat  and  posture.  S. 
Barnett  (N.  Y.  Med.  Record,  vol.  xxxii, 
p.  761,  1887). 

Case  5.  Amount  not  known.  Patient 
intoxicated  at  the  time.  Symptoms  of 
acute  poisoning.  Recovery.  Emetics, 
brandy,  ammonia,  and  digitalis  by  the 
mouth.  Sixty  minims  of  tincture  of 
digitalis  hypodermically.  Heat.  Clara 
T.  Dercum  (Med.  and  Surg.  Reporter, 
vol.  Ixi,  P.T889). 

Case  6.  Tincture,  amount  not  known. 
Child,  16  months.  Marked  toxic  symp- 
toms. Recovery.  Brandy  and  fluidex- 
tract of  digitalis  frequently  repeated  in 
spite  of  vomiting.  Byron  F.  Dawson 
(Med.  and  Surg.  Reporter,  vol.  Ixii,  p. 
7,    1890). 

Case  7.  Tincture,  2  drams.  Death. 
Benjamin  Edson  (N.  Y.  Med.  Record, 
vol.  xxxviii,  p.  365,  1890). 

Cases  8,  9,  and  10.    Dr.  Edson  men- 
tions certain  other  cases  known  of,  but 
not  treated  by  him,  three  of  which  died. 
The    amounts    taken    in    these    were 
from  1  to  4  drams. 

Case  11.  Tincture  (B.  P.),  1  ounce. 
Death  in  sixty-five  minutes.  Mustard, 
lavage,  heat,  ether,  and  brandy  subcu- 
taneously.  L.  M.  Whannel  (Brit.  Med. 
Jour.,  vol.  ii,  p.  791,  1890). 

Case  12.  Fleming's  tincture,  1  dram. 
Recovery.     Sulphate  of  zinc,  tincture 


of  digitalis,  20  minims  hypodermically. 
Whisky,  1  ounce,  by  the  mouth,  fol- 
lowed by  calomel,  8  grains.  L.  M. 
Whannel  (Brit.  Med.  Jour.,  vol.  ii,  p. 
791,  1890). 

Case  13.  Fleming's  tincture,  1  tea- 
spoonful.  Recovery.  Mustard,  spirit 
of  ammonia  comp.  (B.  P.),  tincture  of 
belladonna,  brandy.  T.  F.  H.  Smith 
(Brit.  Med.  Jour.,  vol.  i,  p.  1109,  1893). 
Case  14.  Fluidextract,  4  drams. 
Recovery.  Emetics,  atropine,  and 
brandy  subcutaneously.  Henri  E.  R. 
Altenloh  (N.  Y.  Med.  Jour.,  vol.  Ixvii, 
p.  358,  1893). 

Case  15.  Tincture,  7>^  drams.  Re- 
covery. Mustard,  digitalis,  and  brandy 
subcutaneously;  digitalis,  nux  vomica, 
and  brandy  by  rectum ;  ether  and  am- 
monia by  inhalation;  brandy  and  am- 
monia carbonate  by  mouth  later.  G.  H. 
Tuttle  (Boston  Med.  and  Surg.  Jour., 
vol.  XXV,  p.  678,   1891). 

Case  16.  Mentioned  by,  but  not  seen 
by,  Dr.  Tuttle.  Tincture,  5^4  drams. 
Death.  G.  H.  Tuttle  (Boston  Med.  and 
Surg.  Jour.,  vol.  xxv,  p.  678,  1891). 

Case  17.  Preparation  not  noted.  Four 
teaspoonfuls.  Recovery.  Sulphate  of 
copper,  digitalis,  wine  by  mouth; 
whisky  by  rectum ;  whisky,  ^25  grain 
strychnine,  and  digitalin,  %o  grain, 
hypodermically.  M.  A.  Warriner  (N. 
Y.  Med.  Record,  vol.  xxxix,  p.  521, 
1891). 

Case  18.  Tincture,  2  drams.  Recov- 
ery. Apomorphine,  stomach-tube, 
tincture  of  digitalis,  25  minims;  aro- 
matic spirit  of  ammonia,  45  minims; 
brandy,  2  drams  subcutaneously,  heat- 
ers, sinapism  to  precordia.  S.  Q. 
Robinson  (Boston  Med.  and  Surg. 
Jour.,  p.  192,  1892). 

Case  19.  Tincture  (B.  P.),  30  minims. 
Recovery.  Salt  and  water  one  and  a 
half  hours  after  poison.  Sulphate  of 
zinc  two  hours  after  poison.  Charcoal, 
brandy,  and  water  by  mouth.  William 
Hardman  (Brit.  Med.  Jour.,  p.  1893). 
Case  20.  Preparation  not  stated.  Five 
drops.  Recovery.  Belladonna  and 
strophanthus,  champagne,  brandy, 
heaters.  J.  D.  Leigh  (Edinburgh  Med. 
Jour.,  vol.  xl,  p.  638,  1895). 


282 


ACONITE    (SAJOUS). 


Reported  by  R.  W.  Greenleaf  (Bos- 
ton Med.  and  Surg.  Jour.,  July  15, 
1897).  [The  tincture  of  aconite  re- 
ferred to  is  that  of  the  old  U.  S.  P. — 
Ed.] 

Case  of  a  man,  aged  26,  ^vho  drank 
about  three-fourths  of  an  ounce  of  the 
tincture  of  aconite.  He  immediately 
discovered  his  mistake,  and  took  about 
a  tablespoonful  of  ground  mustard  in 
water,  but  could  not  vomit.  The  writer 
administered  vider  vinegar  about  fif- 
teen minutes  after  drinking  the  aconite. 
He  drank  about  a  half-pint  and  another 
half-pint  out  of  a  quart  jar.  In  less 
than  five  minutes  he  was  greatly  re- 
lieved, and  his  pulse  was  much  better. 
The  vinegar  almost  immediately  re- 
■  lieved  the  burning  and  choking  sensa- 
tion in  his  throat.  His  saliva,  which 
was  thick  and  stringy  (hanging  down 
three  or  four  feet,  at  the  writer's  ar- 
rival, on  his  attempt  to  spit),  did  not 
change  its  character  for  at  least  half 
an  hour.  It  gradually  became  normal. 
All"  the  symptoms  gradually  subsided. 
C.  M.  Swincle  (Homeo.  Recorder,  Oct. 
15,  1908). 

[The  best  remedies  used  in  the  cases  col- 
lected b}^  Dr.  Greenleaf  were,  from  my  view- 
point, besides  belladonna:  digitalis,  strych- 
nine, coffee,  ether,  and  strcphanthus,  all  of 
which,  though  indirectly  in  most  instances, 
tend  to  stimulate  the  sympathetic  center. 
Morphine,  used  by  Dr.  Brick,  excites  directly 
the  sympathetic  center  (as  do  the  coal-tar 
products),  but  not,  as  does  belladonna,  in 
such  a  way  as  to  restore  the  propulsive 
activity   of   the   arterioles. 

Dr.  Swincle's  successful  use  of  vinegar  is 
of  special  interest  in  view  of  the  fact  that, 
as  stated  in  the  section  on  Acetic  Acid  (this 
volume,  p.  229),  I  ascribe  the  toxic  action 
of  this  agent  to  reflex  excitation  of  the  sym- 
pathetic center.     C.  E.  de  M.  S.] 

THERAPEUTICS.  —  Aconite  is 
mainly  used  as  a  circulatory  sedative. 
It  lessens  the  blood-pressure  b}^  dimin- 
ishing the  force  and  rapidity  of  the 
heart's  action,  and  is,  therefore,  indi- 
cated where  a  frequent  and  tense  pulse 
is    associated    with    excessive    cardiac 


activity.  It  also  tends  to  counteract 
spasm  and  relieve  undue  excitability 
of  the  nerve-centers,  though  its  prop- 
erty of  depressing  the  cutaneous 
sensory  nerve-terminals  is  more 
marked,  and  is  frequently  availed  of 
in  neuralgic  affections. 

Aconite  causing  increased  respira- 
tion, it  is  indicated  where,  with  a 
high  pulse,  there  is  dryness  of  the 
skin.  The  evaporation  of  sweat  from 
the  surface  and  the  heat  radiation 
due  to  the  increased  peripheral  circu- 
lation resulting  from  relaxation  of 
the  cutaneous  capillaries  also  cause  a 
reduction  of  temperature.  Aconite 
also  possesses  diuretic  properties. 
Hence  it  appears  to  be  endowed  with 
all  the  qualities  requisite  in  the  in- 
cipient stage  of  uncomplicated  in- 
flammatory disorders,  as  an  anodyne 
sedative. 

In  children  aconite  may  be  given 
whenever  the  spasmodic  element  is 
clearly  marked:  in  fever  preceding  at- 
tacks of  quinsy,  pharyngitis,  etc. ;  in 
asthma  and  the  asthmatic  crises  of 
bronchial  adenopathy ;  in  pertussis 
and  other  spasmodic  coughs;  in 
laryngismus  stridulus ;  in  palpitations 
associated  or  not  with  hypertrophy  of 
the  heart,  and  in  convulsions. 

[The  foregoing  symptomatic  indications 
are  not  approved  by  the  writer,  being  merely 
offshoots  of  the  prevailing  empirical  (and 
therefore  unscientific)  methods  in  the  use 
of  remedies.  It  is  not  to  '"allay  spasm,"  to 
"reduce  the  heart's  action,"  or  to  "reduce 
fever"  that  aconite  should  b^  given,  but 
only  where  it  may  aid  the  curative  process 
or  offset  complicati- IS  as  shown  below. 
C.  E.  DE  M.  S.] 

The  physiological  effects  enumerated 
afford  sufficient  ground  for  its  value  in 
the  reduction  of  all  the  phenomena  at- 
tending the  fever:  high  temperature, 

dry  skin,  hard  and  frequent  pulse,  etc. 


ACONITE    (SAJOUS). 


283 


The  tincture  is  preferable  here,  as  it  is 
in  all  other  disorders.  The  best  effects 
are  produced  by  means  of  small  doses. 
One  minim  is  first  given,  then  another 
minim  in  one-half  hour.  After  that, 
P/2  minims  are  given  every  half-hour 
until  the  febrile  symptoms  are  reduced 
or  until  physiological  symptoms  of  the 
drug  appear.  Aconite  should  always 
be  greatly  diluted. 

Its  antipyretic  power  being  less  than 
that  of  certain  newer  remedies  (coal- 
tar  antipyretics),  however,  the  latter 
generally  (though  very  much  less  than 
formerly)  find  more  favor  where  a 
marked  reduction  of  temperature  is 
desired,  unless  the  additional  indica- 
tions for  the  use  of  aconite,  such  as  an 
overactive  heart,  frequent  pulse,  or  dry 
skin,  be  strongly  marked.  Its  action  in 
favoring  perspiration  may  be  enhanced 
by  combination  with  other  diaphoretics, 
such  as  the  alkalies  or  pilocarpine. 

Aconite  is  used  in  the  fever  attend- 
ing the  incipient  stage  of  catarrhal 
disorders.  It  may  be  used  as  an  anti- 
pyretic in  continued  fevers  and  in- 
fectious diseases, — variola,  scarlatina, 
erysipelas,  etc., — but  large  doses  are 
usually  required,  involving  corre- 
spondingly great  danger.  It  is  better 
used  in  moderate  doses  for  general 
sedative  and  diaphoretic  eft'ects  in 
less  severe  infectious  fevers,  such  as 
measles,  mild  scarlatina,  rubella,  and 
in  the  group  of  "ephemeral"  fevers. 
According  to  Tison,  aconitine  re- 
duces the  pain  and  shortens  the 
duration  of  erysipelas;  he  used  acon- 
itine nitrate  in  doses  of  %4o  grain 
every  two  hours,  not  exceeding  10 
such  doses  daily. 

In  the  reflex  fever  which  some- 
times follows  the  use  of  the  catheter 
it  has  been  found  very  efficient  by 
several  observers. 


[In  all  these  conditions  the  use  of  aconite 
should  not  aim  to  reduce  the  fever,  but  to 
aid  in  the  destruction  of  the  pathogenic  sub- 
stances, toxins,  toxic  wastes  of  which  the 
febrile  process  is  attempting  to  rid  the  blood. 
This  is  done  with  the  aid  of  the  small  doses 
indicated  above.  By  producing  a  slight  de- 
pression of  the  sympathetic  center,  these 
small  doses  cause  a  correspondingly  slight 
relaxation  of  all  arterioles;  they  increase  the 
volume  of  blood  admitted  into  the  capillaries, 
and,  these  minute  vessels  being  the  seat  of 
the  active  febrile  process,  they  hasten  its 
activity  and  favor  thereby  the  early  destruc- 
tion of  the  pathogenic  substances. 

Clinical  experience  has  emphasized  the  fact 
that  small  doses  are  alone  beneficial.  From 
the  explanation  I  have  given  of  the  effects 
of  large  doses,  it  is  obvious  that,  by  causing 
excessive  dilatation  of  the  arterioles,  they  can 
arrest  the  febrile  process  and  place  the  pa- 
tient at  the  mercy  of  the  germs  and  their 
toxins.  Large  doses  of  aconite  I  deem  worse 
than  useless.     C.  E.  de  M.  S.] 

In  acute  disorders  of  the  nose,  throat, 
and  lungs  the  sedative  effects  exerted 
by  aconite  upon  respiration  through  its 
influence  upon  the  respiratory  center 
are  added  to  the  qualities  previously 
enumerated.  Hence  its  value  in  acute 
coryza,  pharyngitis,  tonsillitis,  trach- 
eitis, bronchitis,  pleurisy,  and  pneu- 
monia. Dujardin-Beaumetz  uses 
aconitine  when  the  lungs  are  con- 
gested, and  especially  in  influenza. 
In  all  of  these,  2  drops  of  the  tincture 
every  hour  should  be  administered 
until  the  physiological  effects — tin- 
gling and  numbness  of  the.  lips  and 
tongue — are  experienced,  when  the 
remedy  should  be  given  less  fre- 
quently. After  the  initial  stage  of  the 
affections  enumerated,  aconite  should 
be  discontinued,  especially  in  pneu- 
monia, in  which  affection  its  adminis- 
tration is  positively  harmful  as  soon  as 
the  asthenic  stage  begins.  Aconite  has 
been  used  in  hemoptysis  and  epi- 
staxis  to  lower  the  blood-pressure  and 
favor  cessation  of  the  hemorrhage.  In 


284 


ACONITE    (SAJOUS). 


the  chronic  disorders  of  the  respira- 
tory passages — including  phthisis — it 
is  more  hurtful  than  beneficial. 

In  children  aconite  has  proven  useful 
in  coryza,  tonsillitis,  spasmodic 
croup,  asthma,  whooping-cough,  etc. 

[The  principles  outlined  in  the  foregoing 
commentary  are  quite  applicable.  The  phys- 
iological effects  need  not  be  reached,  how- 
ever, to  obtain  salutary  effects.  It  is  in  the 
early  treatment  of  catarrhal  disorders  due  to 
cold  and  exposure  that  aconite  is  most  bene- 
ficial. The  patient  should,  however,  remain 
at  home  owing  to  the  diaphoretic  action  of 
the  remedy,  which  exposes  to  additional  cold 
if  exposed  outdoors.     C.  E.  de  M.  S.] 

Aconite  has  been  employed  in  all 
forms  of  rheumatism,  as  well  as  in 
gout,  to  relieve  pain  and  reduce  con- 
gestion. It  is  especially  indicated 
when  the  skin  is  dry.  It  is  believed 
to  have  particular  value  in  the  acute 
rheumatic  pains  due  to  exposure.  In 
chronic  rheumatism  it  may  be  used 
in  the  form  of  a  2  per  cent,  ointment 
of  aconitine.  Hutchinson  has  found 
tincture  of  aconite  beneficial  in  rheu- 
matic iritis.  He  gives  5  minims  three 
times  a  day,  in  conjunction  with 
potassium  iodide  and  the  alkalies. 

Meningitis,  pericarditis,  and  peri- 
tonitis are  mentioned  concurrently 
owing  to  the  fact  that  their  early 
manifestations  are  equally  influenced 
by  aconite.  In  peritonitis  especially, 
its  effect  as  an  anodyne  tends  to  pre- 
vent vomiting:  an  important  feature. 
In  pericarditis  it  increases  the 
chances  of  recovery  by  reducing  the 
number  of  pulsations,  thus  prolong- 
ing the  resting  periods  between 
beats.  It  should,  however,  be  used 
with  caution  in  these  conditions,  in 
view  of  its  somewhat  variable  general 
depressant  action. 

[It  happens  that  the  four  diseases  referred 
to  in  the  above  two  paragraphs  :   rheumatism. 


meningitis,  pericarditis,  and  peritonitis,  are 
all  ascribed  by  the  writer  to  excessive  activ- 
ity of  the  protective  resources  of  the  body, 
with  autolysis  of  the  tissue  involved  in  these 
conditions  as  the  direct  pathological  process. 
An  important  feature  of  the  latter  is  the 
marked  rise  of  blood-pressure  which  an  ex- 
cess of  antitoxic  bodies  produces;  it  is  this 
feature  that  aconite  counteracts.  By  depress- 
ing the  sympathetic  center  it  causes  relaxa- 
tion of  all  arterioles,  and  thus  lowers  the 
blood-pressure.  It  is  doubtful,  however, 
whether  it  enhances  at  all  the  curative 
process.     C.  E.  de  M.  S.] 

The  sedative  efi^ect  of  aconite  upon 
the  sensory  nerves  and  nerve-endings 
has  led  to  its  frequent  use,  internally  or 
locally,  in  neuralgia  and  neuritis. 
Certain  authors  consider  it  specially 
efi^ective  in  neuralgia  of  the  trifacial 
nerve.  In  neuralgia  of  the  intermittent 
type,  a  combination  of  aconite  with 
quinine  will  often  be  found  serviceable. 
In  the  form  of  neuralgia  characterized 
by  exacerbations  during  damp  weather 
aconite  is  sometimes  efifective  in  small 
doses  frequently  repeated.  If  the  pain- 
ful spot  does  not  cover  much  surface, 
application  of  the  tincture  over  it  with 
a  camel's  hair  pencil  contributes  mark- 
edly to  hasten  the  relief.  The  drug 
may  also  be  applied  as  a  liniment  or  by 
inunction  (see  Modes  of  Administra- 
tion). The  pain  of  neuritis  resulting 
from  exposure  to  cold  is  sometimes 
favorably  influenced  by  aconite.  In 
pain  due  to  disturbances  of  the  central 
nervous  structures,  however,  the  drug 
has  not  been  found  of  great  value. 

[Neuralgia  also  includes  an  abnormal  rise 
of  the  blood-pressure  in  its  pathogenesis,  ac- 
cording to  the  writer's  interpretation  of  this 
disease  (see  "Internal  Secretions,"  p.  1529), 
the  pain  being  the  result  of  congestion  of 
the  nervous  elements  of  the  affected  area 
owing  mainly  to  local  vascular  disorders. 
Aconite,  by  lowering  the  general  vascular 
tension,  relieves  the  pressure  in  the  neuralgic 
area  and  the  pain  due  to  it,     C.  E.  de  M.  S.J 


ACROMEGALY    (LAUNOIS   AND    CESBRON). 


285 


By  lowering  arterial  tension  and 
diminishing  the  number  of  heart-beats 
it  may  be  of  marked  advantage  in  func- 
tional cardiac  disorders,  but  when 
organic  lesions  are  present  it  had  better 
not  be  used.  It  is  not  infrequently 
employed  in  uncomplicated  hyper- 
trophy, in  nervous  palpitation,  and  in 
the  tobacco-heart,  to  antagonize  ex- 
aggerated action,  but  its  effects 
should  be  closely  watched  lest  incip- 
ient degeneration  be  present.  The 
dose  generally  used  is  from  2  to  5 
minims  of  the  tincture  three  times 
daily. 

[One  cannot  be  too  careful  in  using  aconite 
in  cardiac  disorders,  tliough  the  praise  ac- 
corded it  by  various  authors  as  the  ideal 
remedy  for  the  diminution  of  the  blood- 
pressure  when  the  heart  is  exposed  to  ex- 
cessive resistance  is  also  warranted  by  'the 
interpretation  of  its  physiological  action  I 
have  submitted  in  the  foregoing  commen- 
taries.    C.  E.  DE  M.  S.] 

Toward  no  drug  in  the  entire  phar- 
macopeia is  idiosyncrasy  so  often  mani- 
fested. Numerous  cases  are  recorded 
of  dangerous  syncope,  and  even  death 
having  resulted  from  small  medicinal 
doses  of  aconite  .(Ferrand,  Leigh, 
Woodbury).  Ferrand,  indeed,  emphati- 
cally condemns  it  as  a  dangerous  drug 
the  use  of  which  should  be  confined  to 
the  laboratory.  While  few  would  go 
the  full  length  of  Ferrand's  condemna- 
tion, great  caution  is  undoubtedly  nec- 
essary in  its  employment,  owing  to  the 
unexpected  susceptibility  which  is  often 
manifested  toward  its  action.  We  may 
well  pause  before  undertaking  a  more 
extensive  use  of  this  drug  in  cardiac 
therapy.  Arthur  R.  Elliott  (N.  Y.  Med. 
Jour.,  Jan.  9,  1904). 

[Since  the  1905  U.  S.  P.  has  reduced  the 
strength  of  the  tincture,  however,  the  dangers 
to  which  Elliott  refers  have  been  greatly  re- 
duced.    C.  E.  DE  M.   S.] 

A  2  per  cent,  ointment  of  the  alkaloid 
aconitine  has  sometimes  been  applied  to 
relieve   pain  and   itching  in   affections 


such  as  herpes  zoster,  eczema,  pruri- 
tus, etc. 

As  suggested  by  Dr.  G.  W.  Rob- 
erts, a  solution  of  aconite  in  water  is 
very  efficient  in  stubborn  pruritus. 
One  dram  (4  Gm.)  of  the  tincture  in 
8  ounces  (250  Gm.)  of  water  or  twice 
this  strength  may  be  used  to  "bathe" 
the  itching  area,  using  a  soft  cloth  or 
sponge.  H.T.Webster  (Ellingwood's 
Therapeutist,  Sept.  15,  1909). 

Dysmenorrhea  due  to  congestion 
of  the  pelvic  organs,  metrorrhagia, 
and  amenorrhea  resulting  from  ex- 
posure to  cold  have  all  been  mark- 
edly benefited  by  aconite.  In  the 
vomiting  of  pregnancy  aconite  in 
moderately  large  doses  is  often  found 
to  give  relief,  owing  to  its  sedative 
effect  upon  the  nervous  structures 
involved  in  the  reflex  act. 

Aconite  has  been  used  with  benefit  in 
acute  gonorrhea,  1  minim  of  the  tinc- 
ture being  given  every  hour  (Ringer). 
It  is  also  advantageous  as  an  anodyne 
in  epididymitis. 

C.  E.  DE  M.  Sajous 

AND 

L.  T.  DE  M.  Sajous, 

Philadelphia. 


See  Vascu- 
lar System^  Disorders  of,  under 
Acroparesthesia. 

ACROMEGALY :  PIERRE 
MARIE'S  DISEASE. -DEFI- 
NITION.—  Acromegaly  is  a  general 
syndrome  due,  in  almost  every  instance, 
to  tumor  of  the  hypophysis,  character- 
ized by  progressive  enlargement  of  the 
osseous  and  other  supporting  tissues, 
and  primarily  and  chiefly  noticeable  in 
the  extremities. 

[Pierre  Marie  (Revue  de  Medecine,  1886, 
p.  297;  Nouv.  Iconog.  de  la  Salpetriere,  1888; 
Progres  Medical,  March,   1889;  Brain,  1889; 


286 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


Revue  de  Medecine,  Jan.,  1890;  "Legons  de 
clinique  medicale,"  Paris,  1896 ;  Bull,  ct 
Memoires  de  la  Soc.  Med.  des  Hopitaux  de 
Paris,  1896),  in  1885,  wrote  a  monograph 
entitled:  "De  racromcgalie,  hypertrophic 
singuliere,  non-congenitale,  des  extremitcs 
superieures,  inferieures  et  cephalique."  In  it 
he  described  the  deformities  which  he  had 
observed  in  2  cases  from  Charcot's  service  at 
the  Salpetriere,  mentioning  the  increased 
bulk  of  the  hands,  feet,  and  of  certain  facial 
bones  (nasal,  malar,  and  inferior  maxillary), 
the  spinal  curvature,  as  v/ell  as  a  "family 
likeness"  which  suggested  that  the  two  cases 
were  suffering  from  the  same  disease.  This 
affection  he  regarded  as  a  special  morbid 
entity.  He  concluded  his  paper  with  the 
words :  "There  exists  an  affection  especially 
characterized  by  hypertrophy  of  the  feet, 
hands,  and  face,  which  we  propose  to  name 
acromegaly  (from  ^xpo",  extremity;  /j-^yas. 
large),  i.e.,  hypertrophy  of  the  extremities; 
acromegaly  is  entirely  distinct  from  myxe- 
dema, from  Paget's  disease,  and  from  the 
leontiasis  ossea  of  Virchow." 

This  contribution  did  not  appear  until 
April,  1886,  in  the  "Revue  de  Medecine." 
A  new  dystrophy  had  thus  been  added  to  the 
nosologic  gamut.  It  presented  manifesta- 
tions so  peculiar  that  it  could  not  only  be 
differentiated  from  similar  affections,  but 
even  recognized  from  a  di  '  mce.  Verstrae- 
ten  (Revue  de  Medecine,  No.  5,  1889)  and 
de  Souza-Leite  ("De  I'Acromegalie,  Maladie 
de  Pierre  Marie,"  These  de  Paris,  1890) 
very  rightly,  therefore,  designated  acro- 
megaly "Pierre  Marie's  disease." 

It  is  but  fair  to  recall,  however,  that  the 
deformities  had  be-T  mentioned  in  a  number 
of  earlier  communications,  of  which  a  list 
may  be  found  in  a  paper  by  Patry  (These  de 
Paris,  1907).  The  most  striking  observa- 
tions were  those  of  Saucerotte  (Melanges 
de  Chirurgie,  part  i,  p.  407,  1801,  and  Mem. 
de  I'Acad.  de  Chir.,  1772),  of  Alibert  (Precis 
theorique  et  pratique  des  maladies  de  la 
peau,  t.  iii,  p.  317,  Paris,  1882),  of  H. 
Henrot  (Notes  de  clin.  med.  Reims,  1877 
and  1882)  ;  the  last  of  these  dealt  with  a 
case  of  acromegaly  studied  and  examined 
post  mortem  by  one  of  the  writers  of  this 
paper.  These  had  remained  isolated'  obser- 
vations, however,  and  ranked  as  mere  curiosi- 
ties. Once  accurately  known  and  described, 
the  affection  can  be  recognized  in  every  case ; 


for  this  reason  communications  bearing  on 
it  have  been  rapidly  accumulating.  In 
France,  Pierre  Marie  (Nouv.  Icon,  de  la 
Salnetr.,  1888;  Progres  Med.,  March,  1889; 
Brain,  1889;  Rev.  de  Med.,  Jan.,  1890)  com- 
pleted the  data  presented  in  his  first  mono- 
graph. Guinon  (Gaz.  des  Hop.,  No.  128, 
Nov.  9,  1889),  Rauzier  (Nouv.  Montpellier 
Med.,  p.  623,  1893),  and  Blocq  (Gaz.  hebdom. 
de  Med.  et  de  Chir.,  1894)  reviewed  thor- 
oughly, giving  numerous  references,  the 
earlier  communications  on  the  subject,  as  did 
also  Souza-Leite  and  Duchesneau  (These  de 
Lyons,  1901)  in  their  theses.  The  latter  laid 
the  foundations  for  pathological  studies  of 
the  dystrophy.  "In  other  countries,  the  in- 
vestigations bearing  on  this  affection  were 
no  less  plentiful,  as  shown  in  the  tables  pub- 
lished by  Collins  (Jour,  of  Nerv.  and  Ment. 
Dis.,  Nos.  1  and  2,  page  139)  in  1893. 
In  view  of  their  great  number,  we  can  men- 
tion but  a  small  proportion  of  the  authors  on 
this  subject.  In  America:  Adler,  Saundby, 
Duller,  Harris,  Osborne,  Graham,  Hary, 
Packard,  Dercum,  Berkley,  and  Moncorvo 
Diana,  Woods  Hutchinson.  In  England : 
Hadden,  Silcock,  Waldo,  Paget,  Bury,  Kan- 
tack,  Waddel,  Campbell,  Boyce,  and  Beadles 
Whyte.  In  Belgium :  Verstraeten.  In  Ger- 
many :  Virchow,  Erb,  Schiiltze,  Ewald  Ger- 
hardt,  Moebius,  Mosler,  Lethaun,  Boeltz, 
Bier,  Pel,  and  Fraentzel.  In  Italy :  Caselli, 
Sacchi,  Grocco,  Bignani,  Tanzi,  Denti,  Orsi, 
Bruzzi,  Massalongo,  Lombroso.  In  Russia: 
Burchard,  Shaporonikow,  Gorzatchew,  Gaz- 
kienwiczi,   Stembo. 

This  lengthy,  though  very  incomplete  list 
bears  witness  to  the  interest  awakened  in 
medical  circles  by  the  study  of  acromegaly 
since  the  year  1886. 

In  a  second  and  no  less  fruitful  period, 
investigators  sought  to  determine  the  rela- 
tions between  acromegaly  and  gigantism 
[Pierre  Marie  (Legons  de  clin.  med.,  Paris, 
1896;  Bull,  et  mem.  de  la  Soc.  Med.  des 
Hop.  de  Paris,  1896),  Brissaud  et  H.  Meige 
(Jour,  de  med.  et  de  chir.  prat.,  Jan.  25, 
1895;  Nouv.  icon,  de  la  Salpetr.,  1897), 
Meige  (Congres  de  neurol.  de  Grenoble,- 
1902,  and  Arch.  gen.  de  med.,  p.  410,  Oct., 
1902),  Brissaud  (Bull,  de  la  Soc.  Med.  des 
Hop.  de  Paris,  May  15,  1896),  Launois  et  P. 
Roy  (Bull  de  la  Soc.  Med.  des  Hop.  de 
Paris,  May  8,  1903 ;  Nouv.  icon,  de  la  Salpetr., 
1902;    Revue    neurologique,    1903;    "Etudes 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


287 


biologiqucs    sur    les    geants,"     Paris,    1904), 
Pierre  Roy    (These  de   Paris,   1903),  Woods 
Hutchinson     (X.    Y.    Mod.    Jour.,    vol.    Ixxii, 
Nos.    3     and    4,    July.     1900),     Cunningham 
(Trans,  of  the  Royal  Irish  Acad.,  vol.  xxix, 
p.    553,    1891),    Dana    (Jour,    of    Nerv.    and 
Ment.  Dis.,  vol.  xviii,  1893),  Tamburini  (Cen- 
tralhl.   f.  Nervenheilk.,  B.  vii,  p.  625,   1894), 
Tarufifi    (Case    della    macrosomia,    Annali 
univ.    di   med.,    p.    247,    1879),    Massalongo 
(Riforma  med.,  p.  157,  1892)],  to  ascertain 
the  nature  of  certain  manifestations  accom- 
panying   the    deformities,    such    as    ocular 
disorders    [Schiiltze    (Berlin    klin.    Woch., 
No.  2S,  1S89),  Ruttle   (Brit.  Med.  Jour.,  p. 
697,     Mar.    28,    1901),     Pinel-Maisonneuve 
(Soc.     franc,    d'ophthalmol,     Ma}%    1891), 
Bernhardt   (Beitrage  zur  Symptomatol.  u. 
Diagn.       der       Hirngeschwiilste,       Berlin, 
1881)],  glycosuria   [Loeb    (Deutsch.  Arch. 
f>   klin.    Med.,   B.  xxxiv,  p.   449,   1884,  and 
Hypophysis    cerebri    und    Diabetes    mell., 
Centralbl.    f.    inner.    Med.,    1898),    Hanse- 
mann    (Ueber    Akromegalie,    Berlin,    klin. 
Woch.,  p.  417,  1897),  Hinsdale  ("Acromeg- 
aly," p.  20,  Detroit,  1898),  Finzi  (Boll,  della 
Soc.  Med.  di  Bologna,  No.  4,  1894),  Striim- 
pell    (Deutsch.    Zeitschr.    f.    Nervenheilk., 
1897),    P.    E.   Launois  and   P.    Roy    (Arch, 
gen  de  med.,  1903,  and  Bull,  de  la  Soc.  de 
Biol.,   1903)],   the  cerebral  manifestations, 
and   psychic    disturbances    [Soca    (Sur    un 
cas    de    sommeil     par    tumeur   de    I'hypo- 
physe)].     They  were  thus  led  on  to  study 
the  relations  between  various  disturbances 
and  hypophyseal  tumor  formation  [Woods 
Hutchinson,    Modena    (Rivista    speriment. 
di     freniatria,    1903),     Caselli    (Rivista     di 
freniatria,   Feb.,   1900,  and   Reggio-Emilia, 
1900:   Studi  anat.  e   speriment.   sulla  fisio- 
patologia  della  gland,  pituit.),  Launois  and 
Roy    (Autopsie    d'un    geant    diabetique    et 
acromegalique,  Nouv.  icon,  de  la  Salpetr., 
1903),  Klaus  and  van  der  Stricht  (Bull,  de  ' 
la   Soc.   de   Med.    de   Gand,    1893),   Fritsch 
and   Klebs    C'Ein  Beitrag  zur  Pathol,  des 
Riesenwuchses," Leipzig,  1884)], and  to  em- 
phasize the  idea  of  a  distinct  and  charac- 
teristic group  of  symptoms, — the  hypophys- 
eal syndrome, — the  existence  of  which  was 
soon    confirmed   when    the    new   means    of 
exploring  the  cranium  afforded  by  Roent- 
gen's    discovery     was     brought     into    use 
[Beclere   (Bull,  de  la  Soc.   Med.  des   Hop. 
de  Paris,  Dec.  5,  1902;  Presse  med.,  Dec.  9, 


1903),  Giordani  (These  de  Paris,  1906), 
von  Rutkeroski  (Charite,  Annalen,  1904), 
Schiillcr  ("Die  Schadelbasis  ini  Rontgen- 
bild,"  Hamburger  Abl.,  1905)]. 

In  1901,  Frohlich  (Wien.  klin.  Rundsch., 
1901)  pointed  out  the  symptomatic  value 
of  the  adipose  tendency  which  sometimes 
accompanies  the  development  of  pituitary 
tumors;  the  subsequent  observations  of 
Erdheim  (Ziegl.  Beitr.,  Bd.  xxxiii,  1903), 
of  Boyce  and  Beadles  (Jour,  of  Pathol,  and 
Bacteriol.,  pp.  223  and  359,  1893),  of  von 
Hippel  (Virchow's  Archiv,  Bd.  cxxvi,  p. 
124),  Mohr  (Schmidt's  Jahrb.,  Bd.  xxx), 
Closer  (Virchow's  Archiv,  Bd.  cxxii,  p. 
389,  1890),  and  Pechkranz  (Neurol.  Cen- 
tralbl, Bd.  xviii,  p.  202,  1899)  added  pre- 
cision to  our  views  on  this  point.  In- 
deed, the  present  tendency  is  to  divide 
into  two  groups  the  dystrophic  manifesta- 
tions of  the  hypophyseal  syndrome,  some 
being  referred,  on  the  one  hand,  to  the 
true  acromegalic  type  of  Pierre  Marie,  and 
others  to  the  Upomafous  type  of  Frohlich. 

The  third,  or  surgical,  period  in  the 
history  of  acromegaly  [Schlosser  (Wien. 
klin.  Woch.,  1906,  and  May  21  and  23, 
1907),  von  Eiselberg  (Centralbl.  f.  Chir., 
Aug.  29,  t908),  Hochnegg  (ibid.,  p.  72,  and 
Arch.  f.  klin.  Chir.,  Sept.  2,  1908)]  is  of 
recent  advent  (1908).  With  both  great 
boldness  and  assurance,  operators  have  ad- 
vanced to  the  attack  of  the  pituitary  tumor 
itself,  witnessed,  after  its  removalj  regres- 
sion of  the  characteristic  deformities,  and 
brought  out  most  cogent  papers  in  favor 
of  the  hypophyseal  theory  concerning  the 
dystrophy.  Launois  and  Cesbron.] 

SYMPTOMATOLOGY.— Tlie  most 
prominent  characteristic  of  the  "acro- 
megahc  dystropliy"  is,  as  we  have  stated, 
a  progressive  enlargement  of  the  ex- 
tremities. Although  the  deformities  are 
particularly  noticeable  in  naturally 
prominent  portions  of  the  body,  they 
also  involve  other  regions,  such  as  the 
skull,  face,  spinal  column,  and  thorax, 
and  are  very  marked  in  these  regions  as 
well. 

An  outline  of  the  general  appearance 
of  the  acromegalic  patient — that  odd, 
ungainly,  and  unharmonious  creature — 


288 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


may  prove  profitable  before  the  disease 
is  studied  in  detail.  His  enormous, 
clumsy  hands  seem  all  the  more  massive 
from  the  fact  that  the  forearms  have 
retained  their  normal  proportions.  They 
present  a  ''stuffed"  appearance,  and  ter- 
minate in  thickened,  sausage-like  fin- 
gers. His  broadened  feet  are  mere 
paws,  with  toes  of  exaggerated  size. 
The  face  is  long,  the  forehead  narrow 
and  retreating,  and  the  supraorbital 
arches  enlarged;  the  eyes  often  project 
forward  from  between  the  thickened 
eyelids ;  the  nose  stretches  out  laterally 
its  fleshy  ate;  the  lips  are  enormous, 
especially  the  lower,  which  is  everted ; 
the  lower  jaw  is  strongly  prognathic; 
the  tongue,  unusually  large,  frequently 
protrudes  from  the  mouth.  Tliis  repul- 
sive and  beast-like  head,  bounded  later- 
ally by  ears  of  monumental  size,  is  bent 
forward  and  set  deeply  between  the 
shoulders.  Though  of  average  stature, 
or  above  the  average,  the  subject  ap- 
pears partially  collapsed ;  the  curvature 
of  his  back  and  the  thoracic  deformity 
contribute  to  his  humiliation,  which  is 
further  accentuated  by  his  torpid  and 
melancholy  demeanor.  From  a  distance 
his  appearance  is  so  striking  that  the 
diagnosis  can  be  made  without  detailed 
inspection.  When  the  deformities  are 
fully  developed,  all  acromegalics  bear  a 
strong  resemblance,  and  the  adage,  "ab 
nno  disce  omnes"  is  here  truly  appli- 
cable. 

The  increased  bulk  of  the  hands  is 
often  the  first  change  to  attract  atten- 
tion. The  hands  become  broader  and 
thicker  without  augmenting  in  length. 
The  hypertrophy  involves  all  the  com- 
ponent tissues  of  the  part, — bones,  mus- 
cles., subcutaneous  cellular  and  fatty  tis- 
sues, and  skin.  The  latter  is  hard,  firm, 
free  of  edema,  and  somewhat  darkened 
in  color.    The  interphalangeal  folds,  ab- 


normally developed,  extend  between 
what  may  be  called  wads  of  flesh, — ^the 
"main  capitonnee."  The  thenar  and 
hypothenar  eminences  are  greatly  over- 
developed, and  the  linear  grooves  of  the 
palm  are  transformed  into  deep  gutters. 
The  fingers  are  somewhat  flattened 
from  before  backward,  and  are  of  equal 
thickness  distally  and  proximally.  The 
thumb  measures  up  to  12  cm.  in  circum- 
ference* (Lombroso),  the  index  finger 
9  cm.,  and  the  medius  10  cm.  The  nails 
remain  relatively  small.  They  become 
flattened,  turn  up  at  the  edges,  and  show 
longitudinal  striations.  In  exceptional 
cases  a  club-shaped  deformity  of  the 
fingers,  or  the  presence  of  nodosities  at 
the  interphalangeal  joints,  has  been 
noted.  Notwithstanding  the  unusual 
proportions  of  the  acromegalic  hand, 
its  functions  are  generally  preserved, 
complete  flexion  becoming  impossible, 
however,  in  cases  where  the  palm  is 
markedly  thickened.  De  Souza-Leite 
observed  the  "dead  finger"  phenomenon 
twice  in  38  cases. 

In  contradistinction  to  this  massive, 
voluminous,  or  "transverse"  type,  Pierre 
Marie  has  described  a  second  variety  of 
deformity  involving  the  hands.  In  this 
type  they  again  undergo  a  general  in- 
crease in  size,  but  there  is  added  a 
growth  in  length  which  is  about  propor- 
tionate to  that  in  breadth.  Being  longer, 
the  hands  thus  appear  lighter  and  less 
clumsy  than  in  the  massive  form,  where 
the  overgrowth  is  almost  solely  trans- 
verse. This  "longitudinal"  type  is  seen 
more  particularly  in  subjects  in  whom 
the  dystrophy  developed  at  a  relatively 
early  period.  We  have  met  with  it  in 
our  infantile  acromegalic  giants. 

These  deformities  of  the  hand  gen- 
erally stop  at  the  wrist,  at  least  during 
the  earlier  stages.  Later  on,  the  hyper- 
trophy becomes  generalized,  the  other 


Acromegaly.     (P.  E.  Launois.) 


Acromegalic  Profile.     (P.  E.  Launois.) 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


289 


segments  of  the  upper  extremity — fore- 
arm and  arm — being  also  involved. 

The  feet,  like  the  hands,  become 
broader  and  thicker,  without  greatly  in- 
creasing in  length.  They  present  the 
same  fleshy  pads,  surrounded  by  deep 
grooves.  The  skin  is  darker,  but  is  of 
similar  consistency.  The  toes,  especially 
the  great  toe,  reach  altogether  remark- 
able dimensions,  and  the  nails  are  af- 
fected much  as  in  the  upper  extremity. 
According  to  Verstraeten,  the  heels  are 
always  enlarged.  The  h3^pertrophic  en- 
largement generally  terminates  above 
the  leg.  The  knee,  if  early  involved, 
is  enlarged  but  slightly,  and  the  foot  al- 
ways contrasts,  by  its  exaggerated  bulk, 
with  the  rest  of  the  limb. 

The  acromegalic  fades,  besides  the 
characteristics  already  noted,  includes  a 
striking  prominence  of  the  supraorbital 
ridges,  which  project  to  an  extent  cor- 
responcUng  to  the  degree  of  enlarge- 
ment of  the  frontal  sinuses.  The  eyes 
are  lacking  in  expression,  and  appear 
relatively  small  in  comparison  with  the 
capaciousness  of  the  orbits,  notwith- 
standing the  exophthalmos  occasionally 
observed.  The  eyelids  are  thickened 
either  in  toto  or  merely  in  the  region  of 
the  tarsal  cartilages.  The  temporal  fos- 
sae becoming  deeper,  the  malar  promi- 
nences appear  to  stand  out  more 
strongly.  The  nose  undergoes  general 
enlargement,  and  is  distinctly  broadened 
and  flattened.  Its  alze  are  heaviest 
inferiorly,  and  the  septum  is  doubled 
in  thickness.  The  lips  are  enlarged, 
particularly  the  lower,  which  is  also 
everted.  The  mouth,  often  half  open, 
reveals  a  tongue  of  enormous  bulk.  The 
movements  of  the  tongue  are  poorly  ex- 
ecuted; the  organ  interferes  with  mas- 
tication and  articulation,  is  frequently 
injured  by  the  teeth,  and  sometimes 
shows  fissures  at  its  borders.    The  roof 


of  the  mouth,  soft  palate,  f aucial  pillars, 
tonsils,  uvula,  and  larynx  all  exhibit 
hypertrophic  changes.  In  female  sub- 
jects, the  thyroid  cartilage,  in  its  hyper- 
trophied  state,  recalls  the  "Adam's 
apple"  normally  seen  in  the  male. 
Laryngoscopic  examination  reveals  both 
elongation  and  thickening  of  the  vocal 
cords.  These  various  changes  in  the 
organ  of  phonation  impart  to  the  voice 
a  distinctive  deep  and  at  the  same  time 
metallic  quality. 

While  the  alterations  in  the  superior 
maxilla  are  apparently  not  pronounced, 
those  involving  the  lower  jaw  are  some- 
times extremely  marked.  The  chin, 
large  and  massive,  projects  downward 
and  forward,  forming  an  obtuse  angle 
with  the  rami  of  the  jaw-bone.  The 
lower  teeth,  which  Henrot  has  found 
to  be  hypertrophied,  are  spread  apart, 
and,  owing  to  their  forward  projection, 
can  no  longer  be  opposed  to  the  upper 
dental  arch. 

The  profile  is  most  characteristic,  and 
bears  witness  to  the  extraordinary  de- 
gree of  prognathism  sometimes  at- 
tained. The  description  of  the  acro- 
megalic facies  would  not  be  complete 
without  a  mention  of  the  broadened 
ears,  with  their  lobules  of  exaggerated 
size. 

The  facial  skin  is  dry,  brownish  yel- 
low in  color,  and  often  presents  warty 
excrescences.  The  hairs  covering  the 
head  are  individually  thickened,  and, 
taken  collectively,  apparently  exhibit  a 
heavier  growth.  The  eyelashes  and 
other  short  hairy  appendages  are  also 
coarse  and  stiff. 

The  bones  of  the  cranium  proper 
show  modifications  similar  to  those  in 
the  facial  bones.  These  changes  will  be 
described  later,  when  the  results  ob- 
tained by  radiographic  examination  are 
discussed. 

-19 


290 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


In  the  spinal  region,  the  vertebrae, 
taken  as  a  whole,  show  increased  vol- 
ume. As  a  result,  changes  in  the  spinal 
curves  are  brought  about,  consisting, 
more  specifically,  of  a  cervicodorsal 
kyphosis,  with  or  without  lumbar  lor- 
dosis and  scoliosis. 

The  thorax  becomes  more  capacious 
and  undergoes  alterations  in  shape.  It 
becomes  prominent  anteriorly.  Though 
its  anteroposterior  diameter  is  increased. 


Acromegalic  macroglossia,    (P.  E.  Launois.) 

it  is  flattened  laterally.  The  broadened 
sternum  tends  especially  to  spread  out 
above,  and  develops  transverse  ridges. 
The  clavicles  become  thickened  and 
their  curves  exaggerated.  The  ribs 
come  mutually  into  contact,  or  even 
overlap,  and  the  costal  cartilages  become 
ossified.  The  lower  costal  arches  slant 
downward,  sometimes  so  markedly  as 
to  reach  the  crest  of  the  ilium  when  the 
subject  is  in  the  sitting  posture.  The 
scapulae  are  thickened,  and  their  acro- 
mial and  coracoid  processes  stand  out 
in  bold  relief  beneath  the  skin. 

These  deformities  interfere  in  some 
degree  with  the~  thoracic  excursions, 
sufficiently  so,  indeed,  to  bring  about. 


among  acromegalic  subjects,  a  modifi- 
cation in  the  type  of  breathing,  which 
becomes  permanently  abdominal.  When 
they  are  all  present  in  the  same  patient 
and  are  very  pronounced,  a  double  hump 
in  the  back  may  be  pronounced,  recall- 
ing the  classic  conformation  of  the  Ital- 


Cervicodorsal  kyphosis  in  a  case  of 
acromegaly.    iPierre  Marie  ) 

ian  Punchinello,  whom  Pierre  Marie 
considers  the  ancestor  of  acromegalics. 
The  dystrophy  makes  its  first  appear- 
ance at  the  distal  ends  of  the  extremi- 
ties. The  patient's  attention  is  often 
attracted  to  the  condition  by  the  con- 
stantly increasing  tightness  of  his  gloves 
and  footwear.  In  some  instances  the 
family  or  neighbors  notice  changes  tak- 
ing place  in  the  facies.  Once  estab- 
lished, the  affection  progresses  steadily 
and  more  or  less  rapidly.    If  the  patient 


Acromegaly  in  the  Aged— Strabismus.     (P.  E.  Launois.) 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


291 


1)C  a  woman,  she  becomes  aware  of  the 
prDyressively  larger  size  of  thiml)le  she 
re<.|uires  in  her  sewing.  The  male  pa- 
tient, on  the  other  hand,  is  struck  by  the 
increasing  tliameter  of  his  headgear. 

From  the  distal  portions,  the  changes 
proceed  to  the  proximal  segments  of 
the  liml)s,  which,  b}-  their  hypertrophy, 
may  assume  a  markedly  athletic  aspect. 
Muscular  power,  however,  almost  al- 
ways shows  a  gradual  decrease ;  not- 
withstanding their  bulk,  the  contractile 
jKiwer  of  the  muscles  does  not  bear  the 
normal  ratio  to  their  size.  A  certain 
degree  of  muscular  atrophy  has  occa- 


turbanccs.  His  pupil,  J.  B.  Fournicr  (These 
de  Paris,  1896),  having  collected  25  cases, 
including  12  with  autopsy,  was  led  to  distin- 
guish two  varieties  of  cardiac  hypertroph}-, 
the  one,  slight  and  without  degeneration  of 
the  muscular  libers ;  the  other,  accompanied 
by  sclerosis  and  atrophy  of  the  contractile 
elements.     Launois  and  Cesbron.] 

Symptomatically  these  changes  in  the 
cardiac  tissues  find  their  expression  in 
palpitations,  arrhythmia,  and  dyspnea, 
and  may  result  finally  in  asystole.  Syn- 
copal attacks  are  said  to  be  not  uncom- 
mon. Spinal  deformities,  when  marked, 
may  result  in  dilatation  of  the  right 
heart. 


Series  of  thimbles  used  by  an  acromegalic  woman. 


sionally  been  noted ;  in  a  case  studied 
by  Duchesneau  (These  de  Lyon,  1901) 
it  was  so  pronounced  as  to  lead  this 
observer  to  suggest  the  advisability  of 
differentiating  an  amyotrophic  form  of 
the  disease.  The  muscles  show  no  note- 
worthy electrical  disturbances ;  their  ex- 
citability is  diminished  according  toErb, 
exaggerated  according  to  Verstraeten. 
The  patellar  reflexes  are  either  normal, 
diminished,  or  lost;  they  are  never  ex- 
aggerated. 

In  certain  joints,  such  as  the  knee, 
wrist,  and  elbow,  there  have  been  ob- 
served enlargement  and  painful  crac- 
kling, recalling  somewhat  the  phenom- 
ena noted  in  mild  arthropathies. 

The  circulatory  system  presents  an 
interesting  group  of  alterations.  Vari- 
cose veins  are  said  to  be  frequent,  and 
the  heart  is  often  hypertrophied. 

[In  1895  Huchard  pointed  out  the  existence 
of  more  or  less  marked  cardiovascular  dis- 


Hypertrophy  of" the  lymphatic  vessels 
and  glands  has  also  been  reported.' 

Sensation,  on  the  whole,  does  not  ap- 
pear to  be  affected.  Unusual  sensitive- 
ness to  cold  is,  however,  present  to  a 
certain  extent. 

The  various  deformities  that  we 
have  described  arise  and  progress,  as  a 
rule,  without  giving  rise  to  pain.  In 
some  instances,  however,  their  develop- 
ment is  accompanied  by  more  or  less 
severe  painful  crises,  sometimes  re- 
ferred to  the  viscera,  at  other  times  to 
the  limbs.  While  sometimes  taking  the 
form  of  a  simple  myalgia,  they  may  also 
develop  into  severe  neuralgia,  and  are 
then  aggravated  by  exposure  to  cold 
and  dampness.  This  painful  form  of 
the  disease  (Sainton  and  State,  Revue 
Neurologique,  p.  30,  1900,  and  These  de 
Paris,  1900)  may  also  assume  the  rheu- 
matoid type  when  it  becomes  localized 
in  a  certain  group  of  joints. 


292 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


THE  HYPOPHYSEAL  SYN- 
DROME.— Until  recent  years  the  nat- 
ural history  of  acromegaly  would  have 
been  covered  by  a  description  such  as 
the  above.  The  advances  since  made, 
however,  both  along  clinical  lines  and 
in  the  pathology  of  the  disease,  owing 
to  the  use  of  the  X-rays  and  to  im- 
proved histological  technique,  have 
brought  about  modifications  of  our  ear- 
lier ideas.  Previously  considered  an  in- 
dividual affection,  to  which  the  name 
"Pierre  Marie's  disease"  had  properly 
been  applied,  acromegaly  was  found  to 
be,  in  reality,  only  the  most  peculiar  and 
striking  component  of  the  syndrome  re- 
sulting from  tumors  of  the  hypophysis, 
and  it  is  because  it  has  drawn  our  atten- 
tion to  the  hypophysis  that  the  syn- 
drome due  to  hypophyseal  growths  has 
brought  forth  such  a  wealth  of  litera- 
ture as  to  make  it  at  present,  perhaps, 
the  most  abundantly  discussed  of  the 
syndrome  caused  by  brain  tumors. 

We  consider  acromegaly  to  be  an  in- 
tegral part  of  the  hypophyseal  syn- 
drome, and,  indeed,  with  the  exception 
of  certain  rare  cases  acromegaly  unac- 
companied by  tumor  of  the  hypophysis 
does  not  occur,  while,  on  the  other  hand, 
the  close  relationship  of  the  disease  to 
such  tumors  seems  established. 

[The  rare  cases  referred  to  are  critically 
reviewed  in  the  important  papers  of  Woods 
Hutchinson  (N.  Y.  Med.  Jour.,  Nos.  3  and 
4,  July,  1900),  and  of  Modena  (Rivista  speri- 
mentale  di  freniatria,  Fasc.  iii  and  iv,  1903), 
and  of  which  only  one,  that  of  Bonardi 
(Riforma  medica,  ii,  1893),  is  of  value  as 
evidence.     Launois  and  Cesbron.] 

The  affection  generally  makes  its  ap- 
pearance long  before  the  other  compo- 
nents of  the  syndrome,  which  may  be 
interpreted  as  disturbances  due  to  com- 
pression; on  the  other  hand,  in  no 
case  has  a  tumor  in  the  region  of  the 
hypophysis    been    known    to    produce 


acromegaly  unless  developed  from  the 
hypophysis  itself.  Acromegaly  almost 
certainly  implies  the  existence  of  a 
tumor  of  the  hypophysis.  The  converse 
is,  however,  not  always  true,  every 
tumor  of  the  hypophysis  not  necessarily 
resulting  in  acromegaly. 

Clinically,  tumors  of  the  pituitary,  the 
frequency,  nature  and  characteristics  of 
which  we  shall  mention  later,  betray 
their  presence  by  an  aggregate  of  signs 
and  symptoms  included  under  the  term 
"hypophyseal  syndrome."  We  may 
divide  these  signs  and  symptoms,  fol- 
lowing the  example  of  the  obstetricians, 
into  the  three  following  groups:  1. 
Probable  signs  and  symptoms  of  pitui- 
tary tumor.  2.  Quasi-positive  signs  and 
symptoms.    3.  Positive  signs. 

The  first  are  those  of  brain-tumor 
with  special  localisation.  Through  its 
increased  size,  the  pituitary  expands  the 
bony  fossa  in  which  it  is  lodged  and 
soon  begins  to  project  upward  above  it, 
indenting  the  lower  surface  of  the  cere- 
brum. It  exerts  more  or  less  pressure 
on  the  neighboring  structures,  and 
causes  a  certain  degree  of  increased  in- 
tracranial tension. 

The  earliest  symptom  of  it  is  head- 
ache. The  pain  tends  to  become  local- 
ized anteriorly;  these  patients  often 
complain  of  a  sensation  of  heaviness 
"which  impels  them  half  unconsciously 
to  rub  their  forehead  and  eyes,  as 
one  does  ordinarily  upon  awakening" 
(Rayer).  In  certain  cases,  the  pain  is 
more  definitely  localized. 

[In  a  patient  under  the  observation  of 
Bartels  (Zeitschrift  f.  Augenh.,  xvi,  pp. 
407  and  530,  1906),  it  radiated  even  to  the 
eyes,  and  was  of  great  intensity.  In  other 
instances  mild  neuralgic  states,  as  in  the 
case  reported  by  Infeld  (Sitzungsb.  des 
Vereins  f.  Psych,  u.  Neurol.,  Wien,  1902), 
may  be  present,  or,  again,  severe  involve- 
ment of  the  trigeminal  may  exist.     In  a 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


293 


patient  under  the  care  of  Benda  (Berliner 
klin.  Wochenschr.,  p.  167,  1897),  the  pain 
was  so  severe  as. to  require  removal  of  the 
Gasserian  ganglion.  The  pain  has  like- 
wise been  known  to  extend  into  the  occip- 
ital region  (Bartcls),  and  ever  to  pre- 
dominate there.  Pontoppidan  (Hosp.  Tid., 
1897)  reported  the  presence  simultaneously 


discovery  post  mortem  of  an  almost 
complete  flattening  of  the  basal  convolu- 
tions, whereas  in  life  only  trifling  mi- 
graine had  been  recorded,  becomes  a 
matter  of  surprise. 

Along  with  the  headache  should  be 
mentioned  vertigo  and  vomiting  of  cere- 


Young  acromegalic  woman.    In  lower  right-hand  corner,  same  patient  at  the  age  of  20, 
soon  after  onset  of  the  affection.    {P.  E.  Launois.) 


of  right-sided  trigeminal  neuralgia  and  bi- 
lateral occipital  neuralgia.  The  effects  of 
the  trigeminal  involvement  are  sometimes 
so  severe  as  to  cause  lagophthalmia  or 
neuroparalytic  keratitis,  as  reported  by 
Hirschl  (Wiener  klin.  Wochenschr.,  No. 
10,  1899)  and  Griinwald  (Miinch.  med. 
Wochenschr.,  No.  22,  1895).  Launois  and 
Cesbron.] 

In   some  cases   the   progress  of   the 
disease  is  so  nearly  painless  that  the 


bral  type,  which  are  among  the  usual 
signs  of  intracranial  tumors. 

With  the  symptoms  are  generally  as- 
sociated melancholic  tendencies,  loss  of 
memory,  and  mental  and  physical  tor- 
por. Apathy  sometimes  reaches  such 
a  degree  that  the  power  of  executing 
voluntary  acts  seems  practically  lost.  It 
was  very  pronounced  in  the  peculiar 
case  described  by  Rayer :    "During  the 


294 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


morning  visit,  when  asked  to  rise,  he 
promised  to  put  on  his  clothes  at  once, 
yet  at  5  o'clock  in  the  afternoon,  not- 
withstanding repeated  requests  by  the 
nurse,  he  was  still  in  bed.  When  obliged 
to  relinquish  his  room  in  the  daytime, 
he  would  leave  only  to  sit  motionless 
in  an  armchair  or  to  slumber  in  an  ad- 
joining room.  The  positions  he  assumed 
were  those  of  an  exhausted,  flaccid,  and 
semiunconscious  individual."  Convul- 
sive movements  may  also  be  observed, 
sometimes  confined  to  the  face,  in  other 
instances  involving  the  limbs. 

["Cardinal  de  Bousy,"  as  related  by  R. 
Vieussens  ("Novum  vasorum  corporis  hu- 
man! systema,"  Amsterdam,  p.  245,  1705), 
"at  the  age  of  62  years  was  subject  to  con- 
vulsive movements  affecting  particularly 
the  muscles  of  the  eyes,  lips,  and  tongue. 
At  the  outset  of  the  malady  the  attacks 
were  of  short  duration  and  recurred  only 
at  long  intervals;  later  they  became  so 
frequent  and  were  accompanied  by  pains 
of  such  exceeding  severity  as  to  exert  a 
marked  deleterious  effect  on  the  mental 
faculties,  and  especially  on  the  memory,  of 
the  cardinal,  who  complained,  in  addition, 
of  a  certain  sensation  as  of  movements 
taking  place  within  his  head.  Several  apo- 
plectic attacks  then  occurred.  One  of 
these  strokes  was  so  violent  that  the  pa- 
tient was  stricken  with  right-sided  hemi- 
plegia, which  later  gradually  disappeared." 
The  patient  died  a  short  time  after;  at 
the  autopsy  a  large  tumor  of  the  hypoph- 
ysis was  found.    Launois  and  Cesbron.] 

In  establishing  a  diagnosis  of  brain 
tumor  in  general,  and  of  tumor  of  the 
hypophysis  in  particular,  no  signs  should 
be  overlooked,  and  we  must,  therefore, 
not  forget  to  mention  as  possible  symp- 
toms cramps,  contractures  (Berger, 
Zeitschr.  f.  klin.  Med.,  liv;  Stevens, 
British  Med.  Jour.,  April,  1903),  and 
trismus  (Koster,  Hygieia,  1902).  These 
may  be  related  to  the  coexisting  hydro- 
cephalic condition,  since  they  disap- 
peared, in  a  patient  of  von  Hippel  ( Vir- 


chow's  Archiv,  cxxvi,  p.  124),  upon  the 
removal  of  cerebrospinal  fluid  through 
a  nasal  opening.  The  tremor  observed 
by  Stroebe  and  the  ataxia  of  the  lower 
extremities  reported  by  Henneberg 
(Neurol.  Centralbl,  p.  518,  1902)  are 
probably  to  be  referred  to  some  similar 
cause. 

Peculiar  anomalies  of  taste  occasion- 
ally appear,  consisting  of  strongly  ex- 
pressed desires  on  the  part  of  some  pa- 
tients to  eat  most  unusual  articles  of 
food. 

Tinnitus  aurium,  peculiar  in  that  it 
appears  only  on  the  side  upon  which 
the  patient  is  lying,  has  been  noted 
(Yamaguchi,  Klin.  Monatsschr.  f.  Au- 
genheilkunde,  1903). 

Pressure  may  be  exerted  upon  the 
sinuses  adjoining  the  hypophysis  and 
cause  disturbances  in  th^  venous  circu- 
lation, as  shown  by  facial  edema. 

Among  the  circulatory  changes  that 
may  be  produced  is  to  be  added  to  those 
already  mentioned  the  somewhat  para- 
doxical acceleration  of  the  pulse,  re- 
ported by  Engel  (Inaug.  Dissert., 
Wien),  Rosenhaupt  (Berliner  klin. 
Wochenschr.,  1903),  Infeld,  and  Bar- 
tels. 

A  no  less  singular  manifestation  is 
lowering  of  the  internal  temperature, 
which,  in  a  patient  of  Bartels,  remained 
for  weeks  at  a  time  between  34°  and 
36°  C.  (931/5°  and  96%°  F.)  without 
the  supervention  of  any  sign  of  collapse. 

[The  same  phenomenon  has  been  wit- 
nessed by  Petrina.  In  a  case  reported  by 
Gotzl  and  Erdheim  (Zeitschr.  f.  Heilk., 
1905)  the  temperature  fluctuated  for  three 
weeks  between  35°  and  36°  C,  later  fall- 
ing to  33°  C.  (91%°  F.).  It  would  be 
rather  difficult  at  this  time  to  explain  the 
origin  of  such  disturbances ;  we  shall 
merely  point  out  their  similarity  to  the 
phenomena  observed  in  myxedema,  in  which 
disorder  the  temperature  often  fluctuates 
between  33°  and  35°  C,  and  sometimes  even 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


295 


falls     below     these     figures.     Launois     and 
Cesbkon.] 

Torpor  and  asthenia  are,  as  we  have 
stated,  among  the  ordinary  manifesta- 
tions of  acromegaly.  Exaggeration  of 
these  symptoms,  in  the  hypophyseal 
syndrome,  may  give  the  appearance  of 
"sleeping  spells"  (Soca,  Nouv.  Iconog. 
de  la  Salpetriere,  No.  13,  p.  101,  1900), 
similar  to  those  sometimes  accompany- 
ing cerebral  tumors  (Raymond,  Oppen- 
heim,  Buens). 

True  psychoses  occur  with  extraordi- 
nary frequency  in  cases  of  tumor  of  the 
hypophysis.  Schuster  ("Psychische 
Storungen  bei  Hirntumoren"),  who  has 
made  a  special  study  of  the  psychic  dis- 
turbances observed  in  brain  tumors,  be- 
lieves that  they  are  met  with  in  almost 
one-half  of  the  cases  of  tumor  of  the 
hypophysis.  This  proportion  will  not 
seem  surprising  if  we  recall  the  fact  that 
the  first  pathological  observations  on 
hypophyseal  tumors  were  made  in  asy- 
lums for  the  insane  (Rullier,  Presenta- 
tion a  I'Academie  royale  de  Medecine, 
Oct.  7,  1823).  History  afifords  a  con- 
spicuous example  of  this  in  the  person 
of  Cromwell's  giant  porter,  a  maniac 
with  prophesying  tendencies,  whom  it 
was  found  necessary  to  confine. 

In  the  literature  on  the  pathology  of 
tumors  of  the  hypophysis  we  often  come 
across  the  words  "amaurotic  insanity" 
as  a  heading  in  clinical  records.  This 
accompaniment  of  these  tumors,  long 
overlooked,  was  but  recently  given  due 
emphasis  by  Frohlich,  and  particularly 
by  Cestan  and  Halberstadt  (Revue  neu- 
rologique,  p.  1180,  1903).  The  various 
forms  of  delirium,  delusions  of  persecu- 
tion, mystery,  and  the  manic-depressive 
psychosis  may  be  encountered.  An  in- 
teresting fact  has  been  reported  by 
Moutier  ("Acromegalic:  crises  epilep- 
tiformes  avec  equivalents  psychiques," 


Revue  neurologique,  Nov.  8,  1906)  in 
the  occurrence  in  an  amblyopic  acrome- 
galic of  rather  frequent  epileptiform 
seizures,  due  evidently  to  the  cerebral 
tumor  present.  In  the  intervals  be- 
tween seizures  he  was  subject  to  "absent 
periods,"  during  which  he  would  some- 
times remain  perfectly  still,  or  else  per- 
form a  large  number  of  unreasoning 
acts  of  which  he  lost  all  remembrance 
after  the  attack  had  subsided. 

[In  France,  Brunet  (These  de  Paris, 
1899),  Joffroy,  Roubinowitch  (Bulletin  med- 
ical, 1908),  and  Barros  (These  de  Paris, 
1908)  have  made  special  studies  of  the 
mental  condition  of  acromegalics.  Lau- 
nois AND  Cesbron.] 

Polyuria  and  glycosuria  are  often  en- 
countered in  cases  of  tumor  of  the  hy- 
pophysis. That  the  presence  of  sugar 
was  not  more  frequently  reported  by 
the  earlier  observers  is  due  to  the  fact 
that  they  were  not  in  the  habit  of  ex- 
amining the  urine  in  their  cases  system- 
atically. Loeb  (Deutsch.  Archiv  f. 
klin.  Aled.,  p.  449,  xxxiv,  1884;  Cen- 
tralbl.  f.  innere  Med.,  1898)  was  the 
first  to  point  out  the  frequency  of 
melituria  in  disease  of  the  hypophysis. 
He  explained  it  as  being  due  to  the 
pressure  which  may  indirectly  be  ex- 
erted by  tumors  of  this  gland  on  the 
floor  of  the  fourth  ventricle  and  neigh- 
boring structures. 

[According  to  Pierre  Marie,  glycosuria 
occurs  in  one-half  the  cases  of  acromegaly. 
Von  Hansemann  (Berliner  klin.  Woch- 
enschr.,  p.  417,  1897)  found  it  in  but  12  of 
the  97  cases  he  collected,  and  Hinsdale 
("Acromegaly,"  p.  20,  Detroit,  1898)  in 
but  14  out  of  130.  The  figures  of  these 
last  observers  are  not  to  be  taken  as  stand- 
ards, however,  for  very  often  the  presence 
of  glycosuria  was  not  tested  for.  All  the 
papers  bearing  on  this  question  have  been 
brought  together  in  the  communications 
of  Loeb,  Pineles  (Jahr.  der  Wien.  Krank., 
iv,    1897),    Caselli    (Rivista     di    freniatria. 


.296 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


February,  1900;  "Studii  anatomici  e  speri- 
mentali  sulla  iisiopatologia  della  glandola 
pituitaria,"  ^Reggio-Emilia,  1900),  Launois 
and  Roy  (Nouv.  Iconog.  de  la  Salpetriere, 
1903;  Archives  generales  de  Medecine  and 
Bull,  de  la  Soc.  de  Biol.,  1903;  Bull,  de  la 
Soc.  Med.  des  Hop.  de  Paris,  May  8,  1903; 
Nouv.  Iconog'.  de  la  Salpetriere,  1902;  Re- 
vue neurologique,  1903;  "Etudes  biolog- 
iques  sur  les  geants,"  Paris,  1904;  Pierre 
Roy,  "Contribution  a  I'etude  du  gigan- 
tisme,"  These  de  Paris,  1903).  There  is  a 
tendency  among  certain  authors,  on  the 
basis  of  the  association  of  glycosuria  with 
acromegaly,  to  distinguish  a  special  syn- 
drome, to  which  vonNoorden  ("Handbuch 
der  Stoffwechselskrankheiten,"  vol.  ii,  p. 
45,  1905)  has  given  the  name  "acrornegalo- 
diahetes."    Launois  and  Cesbron.] 

Glycosuria  of  hypophyseal  causation, 
though  more  or  less  constantly  present, 
may  show  wide  variations  in  intensity. 
In  a  patient  of  Finzi  (Boll,  della  Soc. 
Med.  di  Bologna,  No.  4,  1894),  for  in- 
stance, the  sugar,  after  having  been 
present  in  large  amounts,  gradually  dis- 
appeared completely  from  the  urine. 
In  February,  .1888,  Striimpell  (Deutsch. 
Archiv  f.  Nervenheilkunde,  1897)  noted 
a  marked  glycosuria  in  one  of  his  cases. 
In  May  of  the  same  year  the  sugar  had 
disappeared.  It  reappeared  in  October, 
then  did  not  return,  even  after  the  in- 
gestion of  a  large  quantity  of  carbohy- 
drates. These  variations  are  probably 
to  be  explained,  in  common  with  the  oc- 
ular disorders  we  shall  discuss  later,  by 
the  variations  that  may  occur  in  the  size 
of  the  pituitary  tumors.  It  is  rather 
difficult  at  present  to  explain  the  mode 
of  production  of  hypophyseal  diabetes, 
and  the  various  theories  advanced  re- 
garding its  pathogenesis  have  none  of 
them  received  sufficient  confirmation. 

Of  the  176  cases  of  acromegaly  re- 
ported so  far,  35.5  per  cent,  included 
glycosuria  as  a  symptom.  Experiments 
to  ascertain  whether  this  was  due  to 
functional  perversion   of  the   pituitary, 


by  injecting  hypophyseal  extract  ob- 
tained from  men  and  horses  into  dogs 
and  rabbits.  In  dogs  no  uniform  re- 
sults were  obtained,  but  in  rabbits  a 
glycosuria  varying  from  a  slight  trace 
to  4.2  per  cent,  always  occurred.  Bor- 
chardt  (Zeit.  f.  klin.  Med.,  Bd.  Ixvi,  S. 
332,  1908). 

Dallemagne  (Archives  de  Medecine 
experimentale,  1895),  Pineles,  and  von 
Hansemann  have  found  lesions  of  the 
pancreas  at  the  autopsy.  The  first  of 
these  observers,  in  addition,  noted  the 
presence  of  small  gliomatous  forma- 
tions in  the  region  of  the  fourth  ven- 
tricle. 

According  to  Lorand  (Journal  medi- 
cal de  Bruxelles,  1903),  the  glycosuria 
results  from  disturbance  in  the  internal 
secretion  of  the  hypophysis,  and  is  a 
component  of  one  of  the  polyglandular 
syndromes,  to  learn  the  precise  nature 
of  which  investigations  are  now  being 
conducted. 

Loeb  believes  it  due  to  pressure  ex- 
erted on  the  structures  at  the  base  of  the 
brain,  and,  since,  of  all  cerebral  tumors, 
those  developing  from,  or  in  the  neigh- 
borhood of,  the  hypophysis  are  the  most 
likely  to  cause  glycosuria,  he  is  of  the 
opinion  that  a  center  regulating  the 
metabolism  of  sugar  exists  in  this  re- 
gion. The  center  discovered  by  Claude 
Bernard  in  the  floor  of  the  fourth  ven- 
tricle would  thus  not  be  the  only  one  of 
this  kind;  Schiff,  indeed,  appears  to 
have  found  other  such  centers  in  the 
optic  thalami,  crura  cerebri,  and  pons. 
Eckhardt  produced  glycosuria  in  rab- 
bits by  injuring  the  vermis  of  the  cere- 
bellum, and,  returning  to  clinical  and 
pathological  records,  we  may  recall  that 
Lepine  observed  diabetes  in  a  case  of 
softening  of  the  central  gray  nuclei,  and 
Loeb  and  Naunyn  in  cases  of  cerebral 
hemorrhage. 

According   to   the   views   of    Sajous 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


297 


("The  Internal  Secretions  and  the  Prin- 
ciples of  JNIedicine,"  vol.  i,  1903;  vol.  ii, 
1907;  Gazette  des  Hopitaux,  Mar.  10, 
No.  29,  1907),  who  holds  that  a  nervous 
center  exists  in  the  hypophysis,  and  that 
the  several  ductless  glands  are  con- 
nected by  a  nervous  pathway,  a  ready 
explanation  is  afforded.  Diabetes  of 
hy]iophyseal  origin  is  the  result  of  an 
irritation,  a  disturbance  produced  in  the 
nervous  center  which  the  gland  con- 
tains, in  the  same  way  that  the  nerve- 
path,  in  its  bulbar  course,  is  influenced 
by  puncture  of  the  fourth  ventricle. 

Whether  we  adopt  the  view  of  Loeb, 
involving  pressure  changes,  or  that  of 
Sajous,  relative  to  nervous  irritation, 
however,  the  presence  of  an  interme- 
diary is  further  required  for  the  produc- 
tion of  glycosuria.  According  to  some, 
this  intermediary  factor  is  the  pancreas ; 
in  the  opinion  of  Gilbert  and  his  follow- 
ers, it  is  the  liver  which,  under  these 
conditions,  becomes  functionally  over- 
active; according  to  Sajous,  it  is  the 
adrenals,  to  which  he  traced  nerves 
from  the  pituitary,  the  adrenal  secre- 
tion augmenting  through  increased  oxi- 
dation the  production  of  amylopsin, 
wdiich,  in  turn,  increases  abnormally 
the  conversion  of  the  hepatic  glycogen 
into  sugar. 

Rath,  Oppenheim,  Konigshoffer,  and 
Weil  have  reported  polydipsia  together 
with  polyuria  in  the  entire  absence  of 
glycosuria.  Bouchard  has  observed 
peptonuria  and  Duchesneau  phospha- 
turia. 

Among  the  other  disturbances  of  se- 
cretion, frequent  and  copious  szveating 
should  also  be  mentioned. 

The  anatomical  and  functional 
changes  taking  place  in  the  reproductive 
organs  in  acromegalic  cases  were  early 
recognized.  The  penis,  which,  as  Erb 
correctly  remarks,  is  also  an  "axpov,^^ 


sometimes,  though  not  regularly,  attains 
a  greater  size  than  normal.  In  the  fe- 
male, the  clitoris  may  undergo  corre- 
sponding hypertrophy,  and  the  folds  of 
skin  forming  its  prepuce  may  become 
thickened. 

This  enlargement  of  the  genital  or- 
gans should  by  no  means  be  taken  to 
imply  increased  functional  activity.  In- 
deed, male  patients  usually  experience 
a  diminution  of  desire  and  potency, 
wdiich  may  progress  to  complete  loss  of 
the  function.  In  the  female,  the  most 
important  result  is  suppression  of  the 
menses,  which  occurs  so  early  in  the  dis- 
ease that  in  many  cases  it  may  be  con- 
sidered the  initial  event. 

The  primary  increase  in  size  in  the 
genital  organs  soon  gives  way  to  a  true 
atrophy.  In  certain  cases  of  hypophys- 
eal tumor  which  had  not  been  accom- 
panied by  acromegaly,  the  penis  was  ob- 
served to  have  dwindled  to  the  size  of 
the  little  finger,  the  testicles  to  have 
become  small  and  soft,  and  the  pubic 
hair  diminished  in  amount. 

Pechkranz  and  Babinski  were  the  first 
to  report  these  changes.  Roubinowitch 
published  the  interesting  history  of  a 
patient,  previously  studied  by  Pierre 
Marie,  who  developed  acromegaly  after 
childbirth,  and  showed  progressive  atro- 
phy of  the  organs  of  generation. 

On  the  basis  of  published  facts  we 
may  at  present  conclude  that  sexual 
atrophy  can  form  part  of  the  hypophys- 
eal syndrome,  but  that  it  is  not  inva- 
riably a  consequence  of  tumors  of  the 
hypophysis.  Coming  on  in  youth,  these 
tumors  may  cause  arrest  of  development 
of  the  genital  organs ;  appearing  later, 
they  may  cause  retrogressive  changes  in 
them.  The  problem  has  not  yet  been 
solved,  since  it  will  be  necessary  to  de- 
termine more  precisely  in  w^hat  measure 
the  hypophysis  is  capable  of  producing 


298 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


genital  atrophy.  The  experiments  of 
Vassale,  of  Caselh,  and  of  Sacchi  seem 
to  have  demonstrated  that  removal  of 
the  gland  in  young  animals  is  without 
effect  on  their  sexual  development,  but 
these  animals  have  never  survived  any 
length  of  time.  Moreover,  a  certain 
number  of  cases  have  been  known,  in- 
cluding those  of  Schmidt-Rimplex,  of 
Gotzl  and  Erdheim,  of  Babinski  (Revue 
Neurologique,  vol.  viii,  p.  531,  1900), 
of  Pechkranz,  and  of  -Bartels,  in  which 
the  tumor  causing  genital  atrophy  did 
not  involve  the  hypophysis. 

In  our  description  of  the  acromegalic 
dystrophy  we  stated  that  the  hypertro- 
phic changes  witnessed  were  due  to  an 
abnormal  development  in  the  various 
connective  tissues.  This  overgrowth 
may,  however,  be  limited  to  certain 
parts  of  these  tissues,  and  in  particular 
to  the  panniculus  adiposus.  In  1901, 
Frohlich  (Wiener  klin.  Rundschau, 
1901)  drew  attention  to  a  special  va- 
riety of  adipose  overgrowth  occurring 
in  cases  of  tumor  of  the  hypophysis,  and 
attaining  considerable  proportions.  Erd- 
heim (Ziegler's  Beitrage,  Bd.  33,  1903) 
confirmed  the  association  of  these  two 
conditions,  and  a  number  of  cases  have 
recently  been  reported.  The  accumula- 
tion of  fat  under  these  circumstances  is 
steady  and  more  or  less  rapid.  It  may 
reach  an  enormous  extent. 

[A  patient  under  the  observation  of 
Boyce  and  Beadles  (Jour,  of  Pathol,  and 
Bacteriol.,  pp.  223  and  359,  1893)  exhibited 
a  layer  of  fat  several  centimeters  in  thick- 
ness over  the  entire  body.  Adipose  dep- 
osition occurs  in  the  deeper  parts  as  well 
as  superficially,  the  great  omentum,  mesen- 
tery (von  Hippel :  Virchow's  Archiv,  cxxvi, 
p.  124),  heart,  and  liver  (Mohr:  Schmidt's 
Jahrb.,  xxx)  being  invaded.  A  patient 
seen  by  Glaser  (Virchow's  Archiv,  cxxii, 
p.  389,  1890)  had  enormous  cheeks,  which 
were  livid  and  showed  numerous  dilated 
veins;  Pechkranz's  (Neurol.  Centralbl.,  xviii. 


p.  202,  1899)  case  gave  the  impression  of 
one  suffering  from  anasarca,  although 
pressure  on  the  hands  and  feet  failed  to 
bring  out  the  characteristic  pitting  of 
edema.  Stewart  (Boston  Med.  and  Surg. 
Jour.,  No.  21,  1899)  reported  a  similar  ob- 
servation. Launois  and  Cesbron.] 

With  the  adipose  accumulations  are 
often  associated  signs  of  increased  in- 
tracranial tension,  and  at  times,  as  we 
have  remarked,  mental  disturbances. 

We  are  not  as  yet  in  a  position  to  ex- 
plain the  special  involvement  of  the  re- 
serve tissues  in  this  affection,  but  will 
have  to  limit  ourselves  to  recalling  the 
following  interesting  observation  re- 
ported by  Madelung  (Langenbeck's  Ar- 
chiv, Ixxiii,  p.  1066)  :  A  girl  6  years  of 
age,  having  been  shot  in  the  head,  began 
to  put  on  fat  six  months  later.  Her 
weight  doubled  in  the  space  of  three 
years  and  reached  42  kg.  (92  pounds). 
Examination  with  the  X-rays  revealed 
the  bullet  in  the  region  of  the  infun- 
dibulum. 

Myxedema  may  form  part  of  the  hy- 
pophyseal syndrome.  From  the  early 
observation  of  Norman  Dalton  (Lan- 
cet, No.  6,  1897)  to  that  of  Sainton  and 
Rathery  (Bull,  de  la  Soc.  Med.  des 
Hop.,  May  8,  1908),  a  large  number  of 
cases  have  been  reported  which  support 
the  view  that  this  combination  may 
occur. 

The  simultaneous  presence  of  simple 
goiter  and  of  Basedow's  disease  [Lan- 
cereaux  (Semaine  medicale,  1902  and 
1905)]  has  likewise  been  reported.  Al- 
though the  association  of  these  disor- 
ders is  a  point  in  favor  of  the  existence 
of  a  polyglandular  syndrome,  it  would 
be  rash  at  this  time  to  attempt  to  define 
the  latter  precisely. 

Ophthalmic  Disorders. — The  quasi- 
positive  signs  of  the  presence  of  a  tumor 
of  the  hypophysis  are  found  in  a  study 
of   the  ocular   disorders,   which   result 


Lipomatous  Type  of  Frohlich's  Syndrome.     (P.  E.  Launois.) 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


299 


from  the  close  anatomical  relationship 
of  the  pituitary  gland  to  the  optic  path- 
ways. The  visual  disturbances  long  ago 
attracted  and  retained  the  attention  of 
investigators.  Among  the  earliest  ob- 
servations should  be  remembered  those 
of  Meussens  (1705),  and  of  Rullier 
(1823).  Ocular  disturbances  are  also 
mentioned  in  the  papers  of  Rayer  and 
of  Friedreich.  Bernhardt  has  summar- 
ized them  as  follows:  "Slow,  progress- 
ive amblyopia,  terminating  in  absolute 
blindness.  Since  the  latter  does  not  re- 
sult from  increased  intracranial  tension, 
but  is  generally  due  to  pressure  on  the 
optic  tracts,  chiasm,  and  optic  nerves, 
papillary  edema  is  not  generally  present, 
primary  atrophy  taking  place  in  most 
instances." 

As  for  the  events  related  more  par- 
ticularly to  acromegaly,  Pierre  Marie  at 
first  recorded  merely  optic  neuritis  in 
mild  cases,  absolute  blindness  in  ad- 
vanced cases.  Pinel-Maisonneuve  in 
France,  Schiiltze  (Berl.  klin.  Wochen- 
schr..  No.  38,  1889)  in  Germany,  and, 
later,  Boltz  (Deutsche  med.  Wochen- 
schr.,  page  685,  1892),  and  Packard 
(Amer.  Jour,  of  the  Med.  Sciences,  p. 
660,  1892),  sought  to  emphasize  the 
diagnostic  value  of  bitemporal  hemian- 
opsia, i.e.,  loss  of  vision  in  the  lateral 
halves  of  the  two  visual  fields,  with 
preserv^ation  of  central  vision.  Since 
these  earlier  investigations,  numerous 
observations  have  been  collected;  the 
present  tendency,  based  on  these,  is  even 
to  establish  a  distinction  between  tumors 
arising  in  the  hypophysis  itself  and 
those  developing  simply  in  the  hypo- 
physeal neighborhood.  The  former  are 
not,  in  general,  accompanied  by  pro- 
nounced disturbances  of  vision  until  a 
rather  advanced  stage.  The  morbid 
change  in  the  optic  nerve,  however,  al- 
most always  progresses,  and  leads  finally 


to  complete  amaurosis  of  one  or  both 
eyes. 

The  first  sign  afl^orded  on  systematic 
examination  of  the  eyes  is  a  diminution 
of  visual  acuity.  But  slightly  marked 
at  first,  this  generally  undergoes  grad- 
ual increase,  absolute  blindness  being 
reached,  in  most  instances,  only  after  a 
period  of  ten  or  twelve  years.     Ordi- 


Acromegaly  with  tumor  of  pituitary  and 
goiter.    (F.  E.  Launois.) 

narily,  one  eye  is  more  seriously  afifected 
than  its  fellow,  and  shows  amaurosis  at 
an  earlier  period. 

[According  to  Uhthoff  (Zusammenkunft 
der  Ophthalm.  Gesell.,  Heidelberg,  Aug., 
1907),  unilateral  amaurosis  occurs  in  33  per 
cent,  of  the  cases.  In  other  instances  the 
amaurosis  is  bilateral  (16  per  cent.).  The 
latter  condition  may  sometimes  appear  at 
a  very  early  stage  of  the  disease,  as  in 
the  cases  reported  by  Leber  (Archiv  f. 
Psych.,  xxxi,  p.  206)  and  Josefsohn  ("Stu- 
dier  ofver  akromegalie  eck  hypophysis- 
tumor,"  Stockholm,  1903).  In  Henneberg's 
case  total  amaurosis  was  present  thirteen 
years  before  death  occurred.  Launois  and 
Cesbron.1 


300 


ACROMEGALY    (LAUNOIS   AND    CESBRON). 


The  condition  sometimes  runs  a  rapid 
course;  it  may  disappear  for  a  short 
time,  then  return  and  become  definitely 
established.  According  to  Oppenheim 
(Berliner  klin.  Wochenschr.,  No.  36, 
1887,  and  No.  29,  1888),  the  histolog- 
ical structure  of  tumors  of  the  hypophy- 
sis, which  are  frequently  very  vascular, 
bears  a  casual  relation  to  this  "oscillat- 
ing vision."  From  the  rupture  of  ves- 
sels with  their  walls  in  an  embryonal, 
formative  state,  followed  by  more  or 
less  extensive  hemorrhage,  sudden 
blindness  might  result.  Eisenlohr  (Vir- 
chow's  Archiv,  Ixviii,  p.  461 )  reports  the 
case  of  a  man  who,  without  having  pre- 
viously exhibited  any  pronounced  dis- 
turbance, was  suddenly  seized  with 
headache,  vomiting,  somnolence,  and 
convulsive  movements  of  the  upper  ex- 
tremities. At  the  same  time  the  pupils 
were  dilated  and  fixed,  and  double  am- 
aurosis was  present.  The  autopsy  dis- 
closed in  the  sella  turcica  a  rounded  tu- 
mor of  the  size  of  a  cherry,  the  existence 
of  which  had  not  been  suspected  during 
life,  and  which  had  been  the  seat  of  an 
extensive  hemorrhage.  In  like  manner 
Bayley  (Philadelphia  Med.  Jour.,  April, 
1898)  witnessed  absolute  blindness  with 
partial  oculomotor  paralysis  in  a  man 
of  50,  who  afterward  showed  a  hemor- 
rhagic focus  in  the  hypophysis.  With 
these  observations  may  be  grouped  those 
of  Bassoe  (Jour,  of  Nervous  and  Men- 
tal Diseases,  Sept.  and  Oct.,  1903)  and 
Yamaguchi.  In  the  case  of  a  young  girl 
who  suffered  complete  loss  of  vision  in 
three  weeks,  Woolcombe  (Brit,  Med, 
Jour.,  June,  1896)  discovered  the  pres- 
ence of  an  exceedingly  vascular  psam- 
moma. 

Of  still  greater  interest  and  impor- 
tance are  the  alterations  in  the  fields  of 
vision  which  accompany  tumors  of  the 
hypophysis,  and  occur  with  particularly 


remarkable  frequency  in  acromegaly. 
From  the  standpoint  of  diagnosis  they 
are  of  primary  importance. 

In  22  cases  with  autopsy  in  which 
changes  in  the  visual  fields  had  been  re- 
corded, the  percentage  of  each  form  of 
hemianopsia  was  as  follows:  Bitem- 
poral hemianopsia,  23  per  cent. ;  unilat- 
eral temporal  hemianopsia,  23  per  cent. ; 
homonymous  hemianopsia,  9  per  cent. 
Concentric  reduction  of  the  visual  fields 
was  recorded  in  22  per  cent,  of  the 
cases ;  an  irregular  contraction  in  4  per 
cent. ;  in  9  per  cent.,  but  one  quadrant 
was  preserved;  in  13  per  cent,  there  was 
a  central  scotoma. 

Study  of  the  eye  symptoms  in  dis- 
ease of  the  pituitary  body  and  acro- 
megaly based  on  328  autopsies.  Tem- 
poral hemianopsia  is  the  most  constant 
symptom ;  typical  choked  disk  and  slight 
papillitis  each  occurred  in  about  5  per 
cent,  of  the  cases,  simple  atrophic  pal- 
lor of  the  disks  in  20  per  cent.,  and  cen- 
tral scotoma  only  in  occasional  cases. 
Paralysis  of  ocular  muscles,  generally 
afifecting  the  oculomotor  nerve,  occurred 
in  10  per  cent,  of  cases,  and  nystagmus 
in  6  per  cent.  W.  Uhthoff  (Lancet, 
Sept.  4,  1909). 

These  results  will,  at  first  sight,  ap- 
pear somewhat  inconstant.  This  vari- 
ability in  the  alterations  of  the  visual 
fields  is,  however,  to  be  accounted  for 
by  the  fact  that  the  visual  tests  were 
made  at  different  stages  of  the  affection 
in  the  various  cases.  It  is  evident  that 
hemianopsia  and  scotoma  are  the  two 
most  important  of  these  disturbances. 

As  Dejerine  pointed  out,  the  condi- 
tion present  is  not,  strictly  speaking,  a 
true  hemianopsia,  since  its  boundaries 
are  practically  never  regular  in  outline, 
and  the  line  marking  off  the  blind  from 
the  unaffected  portions  of  the  visual 
field  is  never  exactly  vertical.  True 
hemianopsia  can  exist  only  when  the 
lesion,  situated  behind  the  chiasm,  in- 


ACROMEGALY    (LAUNOIS    AND    CESBROX). 


301 


volves  the  visual  pathways  in  that  part 
of  their  course  which  extends  from  the 
decussation  to  the  cerebral  cortex.  At 
the  chiasm  itself  the  nerve-fibers  have 
not  yet  undergone  complete  separation 
into  definite  bundles,  and  it  is  here  that 
we  must  seek  an  anatomical  explanation 
for  the  irregular  hemianopsia  which  ac- 
companies lesions  of  this  portion  of  the 
optic  pathway. 

Moreover,  the  most  varied  combina- 
tions of  the  several  ocular  disturbances 
may  occur.  A  central  scotoma,  for  ex- 
ample, may  be  present  at  first,  hemia- 
nopsia then  appearing  (Pontoppidan), 
or  hemianopsia  may  precede  and  be 
later  supplemented  with  marked  con- 
traction in  the  visual  field  (Striimpell). 
Hemianopsia  and  contraction  are  often 
found  to  coexist. 

Central  scotoma  is  of  very  frequent 
occurrence,  but  does  not  seem  to  possess 
any  special  value  as  an  indication  of  the 
lesion  present,  since  it  has  been  observed 
in  cases  where  the  visual  tracts  ap- 
peared to  be  crushed  by  the  tumor,  and 
it  is  difficult  to  understand  how,  under 
such  conditions,  the  maculopapillary 
fibers  could  alone  be  affected.  Indeed, 
from  the  variations  in  the  extent  of  in- 
volvement of  the  visual  fields  no  con- 
clusion can  be  reached  with  any  degree 
of  certainty  as  to  the  exact  seat  of  the 
lesion.  Changes  in  the  visual  fields  are, 
however,  almost  constantly  present; 
whenever  examined  for  they  have  been 
found,  and  up  to  the  present  time  Schon- 
born's  case  is,  perhaps,  the  only  one  in 
which  they  were  wanting.  This  ob- 
server, moreover,  fails  to  state  whether 
he  studied  the  color-perception  in  his 
patient  or  not. 

Among  the  changes  in  the  eye-grounds 
in  those  suft'ering  from  tumors  of  the 
hypophysis,  simple  optic  atrophy  should 
receive  first  mention.    Papillary  edema, 


on  the  other  hand,  is  of  relatively  rare 
occurrence. 

[Bath,  and  later  various  other  authors, 
among  whom  were  Denti  (Annali  di  Ottal- 
mol.,  XXV,  p.  615),  Sternberg,  Oppenheim, 
and  Schmidt-Rimpler  ("Die  Erkrankungen 
der  Augen  in  Zusammenhang  mit  anderen 
Erkrankungen,"  Vienna,  1905),  found  it  to 
occur  much  less  frequently  than  in  other 
varieties  of  cerebral  tumor.  According  to 
Bartels,  40  cases  with  autopsy  yielded  the 
following  percentages:  Simple  atrophy, 
50  per  cent.;  bilateral  papillary  edema,  15 
per  cent.;  neuritis  followed  bj^  atrophy,  15 
per  cent.;  disks  entirelj'  normal,  20  per 
cent.    Launois  and  Cesbron.] 

The  uncommon  occurrence  of  papil- 
lary stasis  may  be  explained  by  the  le- 
sions resulting  from  direct  compression 
of  the  optic-nerve  bundles.  We  can 
readily  believe,  with  Terrien,  that  an  in- 
timate union  takes  place  very  early  be- 
tween the  nerve-fibers  and  their  sheaths 
in  the  visual  tracts,  and  that  the  adhe- 
sions formed  between  these  structures 
make  it  difficult,  or  even  impossible, 
for  the  cerebrospinal  fluid  to  enter 
the  papilla. 

The  pupillary  reflexes  in  cases  of  hy- 
pophyseal tumor  also  afford  an  inter- 
esting study,  in  conjunction  with  the  dis- 
turbances of  vision  already  mentioned. 
In  general,  it  may  be  said  that  they  are 
always  altered. 

In  a  large  number  of  cases  simple 
amaurosis  is  observed,  with  pupillary 
imm.obility  as  a  consequence.  Thus  in 
a  case  reported  by  Selke  (Inaug.  Dis- 
sert, Konigsberg,  1891),  the  pupils  did 
not  react  either  to  light  or  distance, 
though  the  patient  could  still  distinguish 
light  from  darkness.  In  a  case  of  un- 
usual interest,  Berger  observed  during 
a  period  of  temporary  amaurosis  loss  of 
the  reaction  to  light,  while  the  reaction 
to  distance  was  preserved.  The  light 
reflex  later  reappeared.  In  other  cases, 
where  the  patients  are  still  able  to  recog- 


302 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


nize  objects,  the  reflexes  persist,  but  are 
less  active.  Yamaguchi  has"  even  wit- 
nessed very  slow  response  to  light  in  an 
eye  showing  normal  visual  acuity. 
-  Lastly,  where  hemianopsia  exists,  the 
hemiopic  reaction  may  sometimes  be  ob- 
served. The  well-known  "hemianopsic 
pupillary  reaction,"  discovered  by  Wer- 
nicke, implies  inability  on  the  part  of 
a  visual  field  to  bring  about  pupillary 
action  in  response  to  light  falling  upon 
it.  The  pupillary  fibers  of  the  optic 
nerve  pass  into  the  anterior  corpus 
quadrigeminum ;  from  here  a  relay  of 
fibers  starts  which  places  them  in  con- 
nection with  the  nucleus  of  the  pupil- 
lary sphincter,  located  in  the  central 
gray  matter  of  the  aqueduct  of  Sylvius, 
in  the  anterior  portion  of  the  common 
oculomotor  nucleus.  When  these  pupil- 
lary fibers  are  destroyed,  as  in  cases 
where  the  optic  tract  has  been  crushed 
or  has  disappeared  completely,  the  blind 
half  of  the  visual  field  can  no  longer 
cause  pupillary  action.  This  reaction, 
then,  is  characteristic  of  an  interruption 
in  the  optic  fibers  at  a  point  between  the 
chiasm  and  the  corpora  quadrigemina. 
The  hemianopsic  reaction  of  Wernicke 
is  thus  an  integral  part  and  almost  ex- 
clusively an  attribute  of  the  syndrome 
resulting  from  disease  in  the  hypophys- 
eal region. 

We  must  admit  that  the  presence  of 
this  reaction  does  not  appear  to  have 
been  shown  very  often.  While  Josef- 
sohn  observed  it  very  clearly,  Gotzl  and 
Erdheim,  in  a  case  of  hemianopsia  re- 
sulting from  pituitary  tumor,  were  un- 
able to  find  it.  This  failure  and  the 
dearth  of  confirmatory  observations 
should,  perhaps,  be  attributed  to  the  dif- 
ficulties of  technique  which  fiave  to  be 
overcome  in  order  to  demonstrate  the 
existence  of  this  singular  pupillary  dis- 
turbance,  which  is  possessed  of   such 


great  clinical  value  for  the  localization 
of  brain  lesions. 

Radiographic  Study  of  the  Cranium. 
— As  for  the  positive  signs  of  the  pres- 
ence of  a  tumor  of  the  hypophysis,  they 
are  afforded  by  X-ray  examination  of 
the  cranium. 

No  sooner  had  Roentgen's  discovery 
(1895)  given  us  the  power,  as  Giordani 
expressed  it,  "to  make  of  the  invisible 
an  object"  than  the  X-rays  began  to  be 
utilized  in  the  study  of  the  skeletal  dys- 
trophies, and  of  acromegaly  in  particu- 
lar. Marinesco  brought  out  a  compara- 
tive study  of  the  bones  of  the  hand  in 
acromegaly  of  the  massive  and  the  giant 
types.  The  data  collected  by  Gaston 
and  G.  Brouardel  were  sufficiently  pre- 
cise to  admit  of  the  following  conclu- 
sion^  viz.,  that  "radiographic  studies  of 
the  acromegalic  hand  make  it  possible 
to  trace  the  process  of  central  bony  re- 
absorption  and  the  periosteal  and  carti- 
laginous proliferation  which  Pierre 
Marie  and  Marinesco  observed  in  their 
histological  studies." 

To  Beclere  belongs  the  credit  of  hav- 
ing drawn  from  radiographic  explora- 
tion the  full  measure  of  data  to  be  de- 
rived therefrom  in  the  study  of  the  hy- 
pophyseal syndrome.  His  first  attempts 
were  fruitless  because  of  an  entirely 
abnormal  thickening  of  the  cranial 
bones,  but  his  later  researches,  especially 
those  carried  out  in  cases  sent  him  by 
us,  were  productive  of  more  accurate 
results.  He  witnessed  the  simultaneous 
occurrence  of  three  strongly  character- 
istic changes:  (a)  A  very  irregular 
thickening  of  the  cranial  parietes:  the 
outline  of  the  skull,  instead  of  being 
rounded,  is  polygonal ;  the  external  and 
internal  tables,  always  separated  by  an 
abnormal  space,  alternately  recede  and 
come  together,  giving  a  moniliform- ap- 
pearance on  cross-section,     (b)  Exag- 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


303 


gerated  licight  and  depth  of  the  frontal 
and  maxillary  sinuses,  (c)  A  more  or 
less  marked  increase  in  the  vertical,  and 
especially  in  the  anteroposterior,  dime^i- 
sions  of  the  pituitary  fossa,  which, 
markedly  altered,  in  most  instances  pre- 
sents the  appearance  of  a  cup.  To  these 
primary  modifications  must  be  added 
exaggeration  of  the  postlambdoidal 
promincnee  (Papillaut,  Lannois,  and 
Roy). 


increase  in  the  size  of  the  fossa  can  be 
plainly  appreciated  at  its  posterior  wall. 
Schuller  believes  that  enlargement  of 
the  bony  cavity  is  the  rule,  even  where 
the  tumor  is  of  relatively  small  size,  and 
of  slow,  regalia r  growth.  The  bony  pa- 
rietes  may,  in  certain  cases,  undergo 
pressure  atrophy.  In  cases  of  rapidly 
growing  tumor  they  likewise  disappear, 
being  invaded  by  the  neoplastic  tissue. 
Erdheim   has   established   still    nicer 


Diagram  of  the  acromegfalic  skull,  worked  out  by  P.  E.  Launois  and  P.  Roy,  according  to 
the  X-ray  findings  of  Beclere.  Shows  increased  depth  of  frontal  sinuses,  irregular  thickening' 
of  the  cranial  bones,  abnormal  projection  of  postlambdoidal  eminence,  and  enlargement  of 
sella  turcica. 


By  combining  the  above  data  we  were 
enabled  to  construct  a  diagram  of  the 
acromegalic  skull,  as  shown  in  the  an- 
nexed illustration. 

By  taking  X-ray  pictures  from  the 
facial  aspect  one  can  likewise  learn  of 
the  changes  occurring  in  the  mandible 
and  the  degree  of  prognathism  they  may 
engender. 

German  investigators  have  sought  to 
attain  further  precision  in  their  radio- 
graphic studies.  According  to  von  Rut- 
keroski,  each  time  the  hypophysis  in- 
creases in  volume  the  sella  turcica  very 
rapidly  enlarges  in  all  dimensions ;  the 


distinctions.  According  to  this  author, 
if  the  tumor  remains  limited  to  the  sella 
turcica,  the  latter  enlarges,  but  its  aper- 
ture above  does  not  widen.  If  there  is 
a  tumor  of  the  infundibulum,  the  upper 
aperture  may  enlarge,  but  the  bony  fossa 
is  little  altered.  Lastly,  if  the  tumor 
rises  above  the  sella  turcica  and  bulges 
out  over  it,  the  fossa  flares  out  above, 
presenting  a  broad  superior  opening. 
We  may  agree  with  Furnrohr  ("Die 
Rontgenstrahlen  im  Dienste  der  Neu- 
rologie,"  Berlin.  1906)  and  Sternberg, 
that  these  are  altogether  too  fine  dis- 
tinctions.   All  those  who  have  had  oc- 


304 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


casion  to  study  radiographic  prints  will 
readily  understand  that  it  is  practically 
impossible  to  appreciate  the  trifling  dif- 
ferences of  shading  upon  which  such 
distinctions  must  depend. 


interior  of  the  cranium,  and  that  the 
borders  of  the  sella  turcica  are  clearly 
apparent.  Normally  a  little  cup-like 
cavity,  it  becomes  so  large,  when  a 
tumor  of  the  hypophysis  is  present,  that 


Jean-Pierre  Mazas,  the  griant  of  Jlontastruc  (front  and  back  views).    {Brissaud  and  R.  Meige.) 


It  is,  nevertheless,  a  fact  that  the 
diagnosis  of  tumor  of  the  hypophysis 
cannot  today  be  made  without  the 
assistance  of  the  X-rays.  If,  taking 
advantage  of  the  improved  methods 
introduced  by  Beclere,  w^e  place  in  the 
stereoscopic  apparatus  a  reduced  image 
on  glass,  we  find  that  the  body  of  the 
sphenoid  is  brought  out  in  relief  in  the 


the   tips   of   two,  three,   or   even  more 
fingers  can  be  accommodated  in  it. 

Relationship  Existing  Between  Ac- 
romegaly and  Gigantism. — The  prob- 
lem concerning  the  relationship  which 
gigantism  bears  to  acromegaly  is  one 
of  great  interest.  Our  data  are  now 
sufficiently  accurate  to  allow  of  its 
solution. 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


305 


In  his  original  description,  Pierre 
Marie  had  clearly  separated  the  two 
dystrophies.  Numerous  facts,  however, 
were  soon  garnered  which  tended  to 
overthrow  this  dualistic  viczv. 

[As  early  as  18S9  Virchow  had  found 
reason  to  state  that  acromegaly  was  a  sec- 
ondarj'  condition  of  degeneration  succeed- 
ing upon  the  excessive  growth.  Langer 
(Denkschriften  der  Kaiserl.  Acad,  der 
Wissensch.  in  Wien,  xxxi,  1872),  Fritsche 
and  Klebs  ("Ein  Beitrag  zur  Pathologie 
"des  Riesenwuchses,"  Leipzig,  1884),  Cun- 
ningham (Trans,  of  the  Royal  Irish  Acad- 
emy, xxix,  p.  553,  1891),  Taruffi  (Annali 
universali  di  medicini,  p.  247,  1879),  and 
Tamburini  ("Beitrage  zur  Symptomatolo- 
gie  und  Diagnostik  der  Hirngeschwiilste," 
Berlin,  1881),  in  examining  the  skeletons 
of  giants  preserved  in  the  various  mu- 
seums, found  the  characteristic  deformi- 
ties of  Marie's  disease,  and  Massalongo 
("SuH'acromegalia,"  Riforma  medica,  p. 
157,  1892)  felt  himself  justified  in  conclud- 
ing, without,  however,  adducing  evidence 
of  his  own,  that  acromegaly  was  nothing 
but  a  delayed,  abnormal  form  of  gigant- 
ism. 

Reports  of  autopsies,  including  those  of 
the  Peruvian  giant,  recorded  by  Dana 
(Jour,  of  Nervovis  and  Mental  Diseases, 
Nos.  1  and  2,  p.  139,  1893),  and  of  Lady 
Aama,  recorded  by  Woods  Hutchinson,  as 
well  as  those  performed  by  Buday  and 
Janeso  ("Ein  Fall  von  pathologischen  Rie- 
senwuchs,"  Deutsch.  Archiv  f.  klin.  Med., 
p.  385,  1898),  and  by  Caselli,  soon  afforded  a 
striking  demonstration  of  the  intimate  re- 
lationship existing  between  the  two  dys- 
trophies.    Launois  and  Cesbron.] 

The  question  was  in  reality  brought 
to  a  focus  by  Brissaud  and  Henri  Meige 
(Jour,  de  med.  et  de  chir.  pratiques, 
Jan.  25,  1895 ;  Nouv.  Iconog.  de  la  Sal- 
petriere,  1897.  Meige,  Congres  de  Neu- 
rol, de  Grenoble,  1902,  and  Archives 
gen.  de  Med.,  Oct.,  1902,  p.  410.  Bris- 
saud, Bull.  de.  la  Soc,  Med.  des  Hop.  de 
Paris,  May  15,  1896)  when  they  wrote: 
"The  combination  of  acromegaly  with 
gigantism  is  far  from  being  a  mere  co- 


incidence, a  casual  meeting  between  two 
distinct  pathological  states  :  Gigantism 
and  acromegaly  are  one  and  the  same 
disease.  What  has  not  been  given  suffi- 
cient  consideration   in   their   reciprocal 


Jean-Pierre  Mazas,  the  giant  of  Montastruc 
■  (profile  view)-.    (Brissaud  and  H.  Meige.) 

relations,  however,  is  the  age  at  which 
the  disease  makes  its  first  appearance. 
If  the  stage  in  which  the  bony  over- 
growth occurs  belongs  to  adolescence 
and  youth,  the  result  is  gigantism  and 
not  acromegaly.  If,  later  on,  after  hav- 
ing belonged  to  youth,  in  which  the  stat- 
ure   is    continually    increasing,  it    en- 


1—20 


306 


ACROMEGALY    (LAUNOIS    AND"  CESBRON). 


croaches  upon  the  period  of  completed 
development,  i.e.,  upon  that  phase  of 
life  in  which  no  further  osteogenetic 
growth  takes  place,  the  result  is  a  com- 
bination of  acromegaly  with  gigantism. 

"Gigantism  is  the  acromegaly  of  the 
growing  period ;  acromegaly  is  the  gi- 


Hutchinson  and  of  one  of  us,  published 
in  conjunction  with  Pierre  Roy. 

As  viewed  by  the  adherents  of  the 
imicist  theory,  acromegalic  gigantism  is 
that  form  of  gigantism  in  which  the 
characteristic  loss  of  harmony  between 
structure  and  function  finds  its  expres- 


Acromegalogigantism  in  a  Chinaman.    [Matignon.) 


gantism  of  the  period  of  completed  de- 
velopment; acromegalogigantism  is  the 
result  of  a  process  common  to  gigantism 
and  to  acromegaly,  overlapping  from 
the  period  of  adolescence  into  that  of 
maturity." 

These  constitute  three  fundamental 
propositions,  which  soon  received  con- 
firmation from    the    labors  of  Woods 


sion,  to  a  greater  or  less  extent,  in  the 
usual  symptoms  and  deformations  of 
acromegaly,  after  union  of  the  epiphy- 
ses to  the  diaphyses  has  taken  place, 
whether  this  union  has  been  prompt  or 
delayed. 

In  the  majority  of  giants  almost  all 
the  stigmata  of  acromegaly  may  be 
recognized.       Sometimes    but    slightly 


ACROMEGALY    (LAUNOIS   AND    CESBRON). 


307 


marked,  the  significant  changes  can  be 
detected  only  upon  careful  inspection; 
at  other  times  very  pronounced,  they 
attract  immediate  attention  and  are 
equally  as  striking  as  the  stature  of  the 
individual  afflicted  with  them.    The  dis- 


Bramwell  (Edin.  Med.  Jour.,  Jan.,  1894, 
and  Brit.  Med.  Jour.,  Jan.  6,  1894),  Cun- 
ningham, Peter  Bassoe,  Matignon,  Lau- 
nois,  and  Roy  (only  the  principal  ones 
being  here  mentioned),  the  dystrophy  had 
developed  to  a  marked  degree.  Jean-Pierre 
Mazas,  the  giant  of  Montastruc,  studied  by 


Skull  of  the  giant  Constantin  (profile  view).     {Dufrane  and  P.  E.  Launots.) 


proportionate  size  of  the  hands  and  feet ; 
the  homely,  sometimes  even  repulsive 
facial  aspect ;  the  evident  sagging  of  the 
body,  w^hich  is  often  marked,  make  of 
the  subject's  gigantic  stature  a  distinc- 
tion little  to  be  envied,  even  in  the  eyes 
of  the  layman  who  cannot  recognize  the 
presence  of  acromegaly  in  the  person 
before  him, 

[In  the  cases  reported  by  Brissaud  and 
Meige,  Dana,  Woods  Hutchinson,  Byrom 


Brissaud  and  Meige,  with  his  undersized 
skull,  projecting  superciliary  ridges,  and 
well-marked  prognathism,  his  monstrous 
and  grinning  face,  his  abnormally  long  up- 
per limbs,  his  enormous  hands  and  feet, 
his  arched  back  and  broadened  thorax,  re- 
called precisely  the  appearance  of  an  an- 
thropoid ape;  the  morbid  state  seemed  in 
his  case  to  have  brought  about  a  reversion 
to    the    ancestral   type.     Launois    and    Ces- 

BRON.] 

In  the  course  of  our  investigations  on 
gigantism  we  were  led    to  establish  a 


308 


ACROMEGALY    (LAUNOIS   AND    CESBRON). 


well-defined  distinction  between  two 
types  of  giants,  viz.,  the  infantile  giant, 
in  whom  the  connecting  cartilages  have 
not  undergone  ossification  and  are  still 
able  to  proliferate,  and  the  acromegalic 
giant,  in  whom  these  cartilages  have  be- 


toward  the  acromegalic  type,  later 
merging  into  it  completely.  We  may 
state,  as  a  general  conclusion,  that, 
while  all  giants  are  not  acromegalics, 
at  least  all  those  who  are  not  such  al- 
ready are  apt  to  become  acromegalics. 


Skull  of  the  g-iant  Constantin  (anterior  viewj.    {Dufrane  and  P.  E,  Liunois.') 


come  ossified  and  who  presents  bony 
thickenings.  This  distinction,  having  as 
its  anatomical  basis  the  two  separate 
processes  of  cartilaginous  and  perios- 
teal ossification,  though  a  true  one  mor- 
phologically, does  not  hold  good  indefi- 
nitely in  time,  i.e.,  the  infantile  type, 
having  remained  pure  during  a  certain 
number   of  years,  tends   to  progress 


[Though  able,  in  the  case  of  the  giant 
Ch ,  to  follow  the  fusion  of  two  mor- 
phologically distinct  types  into  a  single 
type,  we  found  it  impossible  to  state  the 
exact  time  at  which  this  fusion  took  place. 
Becoming  more  and  more  evident  as  the 
cartilages  bordering  on  the  epiphyses  di- 
minish in  thickness  and  become  ossified, 
the  fusion  reaches  completion  when  the 
epiphyses  have  entirely,  or  almost  entirely, 
united  with  the  diaphyses.     In  the  skull. 


ACROMEGALY    (LAUNOIS   AND    CESBRON). 


309 


face,  and  extremities  the  acromegalic  de- 
formities then  make  their  appearance  and 
subsequently  undergo  progressive  develop- 
ment. At  the  autopsy  both  the  stigmata 
of  infantilism  and  the  changes  pertaining 
to  acromegaly  proper  are  recognized.     In 


ical  analysis  will  disclose  the  morbid 
manifestations  of  the  hypophyseal  syn- 
drome. That  this  is  true  is  due  to  the 
fact  that  in  all  giants,  whether  in  life 
by  means  of  the  X-rays,  or  after  death 


Base  of  cranium  of  the  elant  Constantin,  showing  marked  enlargement  of  sella 
turcica.    {Dufrane  and  P.  E.  Launois.) 


this  connection  studies  carried  out  on  the 
body  and  skeleton  of  the  giant  Constantin, 
preserved  by  Dufrane  in  the  hospital  at 
Mons,  yielded  striking  results.  The  illus- 
trations shovi^ing  his  skull  and  humerus 
will  convey  more  to  the  reader  than  would 
a   lengthy    description.     Launois   and   Ces- 

BRON.] 

Whatever  be  the  variety  of  gigantism 
encountered,  a  properly  conducted  clin- 


on  the  autopsy  table,  the  existence  of  a 
tumor  of  the  hypophysis  can  be  recog- 
nized. In  10  cases,  taken  from  among 
the  most  recent  and  the  most  thoroughly 
recorded  we  could  find,  it  was  not  once 
lacking.  To  these  direct  observations 
should  be  added  the  results  obtained 
from  studies  of  the  skeletons  of  giants. 
Langer   reports   having   found   an   in- 


310 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


crease  in  the  length,  breadth,  and  depth 
of  the  sella  turcica  in  every  case,  and 
it  is  well  known  that  in  pathological 
states,  as  well  as  normally,  the  dimen- 
sions of  this  bony  fossa  in  the  sphe- 
noid are  those  best  suited  for  its  con- 
tents. 

The  general  conclusion  warranted  by 


Humerus  of  the  giant  Constantin.  Absence 
of  union  of  upper  epiphysis  at  the  age  of  29 
years.    {Dufrane  and  P.  E.  Launois.) 


all  these  mutually  confirmatory  data  is 
that,  whether  associated  with  infantilism 
or  acromegaly,  gigantism  always  occurs 
in  association  zvith  a  tumor  of  the  hy- 
pophysis. This  assertion  cannot,  of 
course,  be  given  as  applying  to  all  future 
observations,  but  in  view  of  its  uniform 
confirmation  by  those  of  the  past  it  is, 
at  least,  very  impressive. 


COURSE    AND    DURATION.— 

Established  acromegaly  is  generally 
observed  in  adults,  male  or  female. 
The  initial  dystrophic  phenomena  ap- 
pear at  the  age  of  18  to  25  years,  i.e., 
at  the  period  in  which,  under  normal 
conditions,  growth  is  continued  and 
completed.  Sometimes  it  is  headache 
which  leads  the  subject  to  consult  a 
physician.  Other  victims,  frightened 
at  seeing  their  hands  and  feet  grow 
larger,  come  to  find  out  the  reason 
for  these  changes.  In  women  the 
outset  of  the  disease  may  be  traced 
with  some  degree  of  probability  to  a 
period  at  which  menstruation  became 
irregular  or  ceased.  We  must  recognize 
that  such  indications  are  rather  vague, 
as  is  also  the  information  obtained  from 
the  past  morbid  history.  Sometimes  in- 
fectious diseases  are  found  to  have  ex- 
isted, and  under  these  conditions  the 
question  arises  in  our  minds  whether 
they  could  not  have  created  a  disturb- 
ance in  the  hypophysis,  as  well  as  in  the 
other  ductless  glands. 

The  dystrophy  seems  to  occur  with 
greater  frequency  in  women  than  in 
men.  Taking  the  combined  statistics  of 
Souza-Leite  and  of  Duchesneau,  we  find 
22  men  were  afifected  as  against  31 
women. 

While  the  onset  of  the  disease  is 
sometimes  delayed  (forty-nine  years  in 
a  case  of  Schwartz),  it  can  also  be  pre- 
cocious, and  the  few  cases  of  this  kind 
recorded  have  made  it  possible  to  de- 
scribe the  acromegaly  of  children  or 
of  adolescents. 

[Virchow,  in  1889,  observed  it  in  a  girl 
11  years  of  age;  Beaven  Rake  (British 
Med.  Jour.,  1893)  reported  the  case  of  a 
young  negro;  similarly,  Valdes-Surmont 
(Presse  medicale,  Sept.  22,  1897)  saw  the 
first  stigmata  appear  at  14  years.  Mon- 
corvo  recently  reported  the  case  of  a  girl 
14  months  old  he  had  observed.    This  au- 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


311 


tlior  does  not,  however,  believe  that  the 
disease  was  congenital,  and  merely  states 
that  everything  points  to  its  having  be- 
come established  very  soon  after  birth. 
Launois  and  Cesbron.] 

Race  is  without  influence  in  the  etiol- 
ogy. Acromegaly  has  been  met  with  in 
all  countries  and  among  all  races.  Di- 
rect hereditary  transmission  has  been 
observed. 

[The  observers  referred  to  are  Bonardi, 
.  Cyon,  Schwoner,  and  Frankel.  E.  Schaffer 
(Neurol.  Centralbl.,  April  1,  1893)  recently 
reported  a  case  of  transmission  from 
mother  to  daughter.  Friedreich  claims  to 
have  observed  the  stigmata  of  acromegaly 
in  two  brothers.  Launois  and  Cesbron.] 

The  dystrophy  follows  a  progressive, 
but  extremely  slow  course,  which  can 
be  divided  into  several  stages.  The  first 
(stage  of  onset),  in  which  the  deformi- 
ties begin  to  develop,  is  followed  by  a 
second  (sthenic  stage),  in  which  they 
attain  their  maximum.  In  this  stage 
the  acromegalic  woman  presents  a  most 
striking  appearance.  The  increased  size 
of  her  body,  accentuated  by  hypertro- 
phy of  the  extremities;  her  peculiar 
countenance,  with  the  lips,  chin,  and 
cheeks  frequently  covered  with  long, 
curly  hair,  and  her  low-pitched  voice, 
all  combine  to  impart  a  masculine  ap- 
pearance, which  is  sometimes  very  pro- 
nounced. In  a  third  stage  the  hypo- 
physeal syndrome  asserts  itself  until  its 
manifestations  are  more  or  less  com- 
pletely present. 

The  duration  of  the  disease  varies 
within  wide  limits  (twenty  to  thirty 
years).  In  this  connection  Sternberg 
recognizes  three  forms  of  the  affection : 
an  ordinary  form,  running  its  course  in 
eight  to  thirty  years,  and  two  rare 
forms,  the  one  benign,  which  may  last 
fifty  years,  the  other  malignant,  des- 
troying life  in  three  to  four  years. 
This  last  form,  seen  only  6  times  out 


of  210  cases,  is  always  associated,  ac- 
cording to  Gabler,  with  an  epithelial 
tumor  of  the  hypophysis. 

PROGNOSIS.— As  for  the  termina- 
tion, it  is  fatal.  The  patient  at  last  in- 
variably succumbs,  either  to  the  effects 
of  a  slowly  developing  cachexia,  to  in- 
tercurrent disease,  or  suddenly  succeed- 
ing an  attack  of  syncope  or  some  cere- 
bral accident. 

If  acromegaly  be  associated  with  in- 
fantile gigantism,  the  data  at  hand  are 
somewhat  more  precise,  and  the  onset 
of  the  disease  can  readily  be  referred  to 
the  growing  period  proper. 

DIAGNOSIS.— The  external  appear- 
ances of  acromegalics  are  so  character- 
istic that  the  diagnosis  is  at  once  mani- 
fest, even  from  a  distance.  There  are 
a  few  disorders,  however,  with  which 
acromegaly  might  be  confounded,  and 
which  it  is  necessary  to  differentiate. 

In  my:{-edema,  the  trunk  and  extremi- 
ties show  enlargement,  which  consists, 
however,  merely  of  an  edematous  infil- 
tration of  the  soft  tissues.  The  thick- 
ened skin  is  bound  down  to  the  sub- 
jacent layers  and  merges  into  them. 
The  round,  puffy  face  of  myxedema  dif- 
fers radically  from  the  ovaloid  face  of 
the  acromegalic  patient,  in  whom,  be- 
sides, prognathism  and  kyphosis  are 
characteristic  features. 

In  Paget' s  disease  of  the  bones  {oste- 
itis deformans)  there  is  increased  thick- 
ness of  the  cranial  bones  and  more  or 
less  marked  bowing  of  the  bones  of  the 
extremities.  The  thickened  femora  and 
tibia  are  strongly  curved  inward  and 
forward,  the  legs  are  widely  separated, 
and  the  trunk  and  neck  are  fixed  in  a 
position  of  pronounced  flexion.  In  this 
affection  the  bones  of  the  cranium  are 
those  involved,  whereas  in  acromegaly 
the  facial  bones  are  rather  affected.  In 
the  limbs  the  changes  are  limited  to  the 


312 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


diaphyses  of  the  long  bones,  whereas 
acromegaly  shows  a  marked  predilec- 
tion for  the  bones  of  the  extremities 
and  the  extremities  of  these  bones. 
Paget's  disease,  moreover,  seldom  ap- 
pears before  the  age  of  40,  and,  differ- 
ently from  acromegaly,  attacks  the  va- 
rious bones  without  order  or  symmetry. 

Under  the  name  of  leontiasis  ossea 
Virchow  described  a  condition  associ- 
ated with  hyperostosis  of  the  facial  and 
cranial  bones.  The  lumpy  appearance 
of  the  exostoses  and  the  normal  propor- 
tions of  the  hands  and  feet  are  sufficient 
to  preclude  all  doubt  as  to  the  nature  of 
the  affection. 

In  erythromelalgia  the  face  remains 
unchanged.  The  hypertrophic  process 
involves  only  the  soft  tissues  of  the  feet 
and  hands,  and  is  associated  with  an  al- 
together peculiar  cyanotic  hue  of  the 
integument. 

Certain  cases  presenting  a  combina- 
tion of  the  stigmata  of  rickets  and  of 
the  lymphatic  diathesis  might  be  taken 
for  acromegalics.  They  exhibit  clumsy 
hands  and  large  feet,  the  lower  lip  is 
thickened  and  everted,  and  the  face  is 
somewhat  puffy.  But  the  extremities 
show  nodal  deformities  of  a  special 
type,  while  prognathism,  as  well  as 
macroglossia,  are  completely  absent. 

It  is  in  liypertrophic  pidmonary  osteo- 
arthropathy, the  dystrophic  affection 
seen  among  inveterate  coughers,  that 
confusion  with  acromegaly  most  readily 
arises. 

Pierre  Marie,  who  was  the  first  to 
recognize  and  describe  this  form  of  sys- 
tematized osteopathy,  showed  clearly, 
in  a  striking  comparison  he  made  of 
the  two  conditions,  that  the  features 
wherein  they  differ  are  more  numerous 
than  their  points  of  similarity.  In  both 
affections  there  is  symmetrical  hyper- 
trophy of  the  upper  and  lower  extremi- 


ties, together  with  spinal  curvature. 
But  in  pulmonary  osteopathy,  the  hyper- 
trophy, which  is  not  uniformly  distrib- 
uted, is  associated  with  distinct  deform- 
ity of  the  parts  affected.  The  spinal 
curve  is  altogether  different  from  that 
of  acromegaly,  and  prognathism  is  ab- 
sent. The  changes  are  strictly  confined 
to  the  bony  tissues.  In  the  hands,  the 
distal  phalanges  are  clubbed,  resembling 
drumsticks ;  the  nails  are  lengthened, 
broadened,  curved  like  a  parrot's  beak, 
and  show  cracks  and  longitudinal  stria- 
tions. 

The  carpal  and  metacarpal  regions 
are  practically  normal.  The  wrist,  how- 
ever, is  thickened  and  greatly  deformed. 
In  the  feet,  the  distal  phalanges  are 
clubbed,  the  tarsus  and  metatarsus  rel- 
atively normal,  and  the  malleoli  hyper- 
trophied  in  all  dimensions  to  such  an 
extent  that  the  lowxr  part  of  the  leg 
is  thicker  than  the  middle.  In  ad- 
dition, all  the  long  bones  of  the  limbs 
are  thickened,  though  miore  markedly 
in  the  leg  and  forearm  than  in  the  thigh 
and  arm.  The  joints  are  involved  in 
these  changes;  their  enlargement  inter- 
feres with  ease  of  motion,  both  active 
and  passive.  Furthermore,  kyphosis  is 
not  constantly  present,  and  when  it  is 
present  is  confined  to  the  lower  dorsal 
or  lumbar  regions.  In  the  face,  the  su- 
perior maxillary  bone  is  alone  thick- 
ened, the  mandible  remaining  normal. 

Pulmonary  osteoarthropathy  may  give 
rise  to  some  little  difficulty  in  diagnosis, 
principally  owing  to  its  rarity.  It  is 
most  likely  to  be  confounded  with  acro- 
megaly, but  in  the  latter  disease  there 
is  no  alteration  of  the  nails,  nor  are  the 
finger-ends  nor  the  carpus  and  meta- 
carpus much  thickened.  The  chief 
characteristics  of  the  disease  are  great 
enlargement  of  the  hands,  wrists,  feet, 
and  ankles,  associated  with,  and  second- 
ary to,  some  chronic  pulmonary  affec- 
tion, such  as  phthisis,  chronic  bronchitis, 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


313 


and  empyema.  In  the  joints  the 
changes  arc  effusion  with  enlargements 
and  ulceration  of  the  cartilages  and 
articular  ends  of  the  bones.  Marie  is 
of  the  opinion  that  these  changes  are 
due  to  toxic  poisoning,  but  Thorburn 
looks  on  them  as  tuberculous.  The 
evidence  either  way  is  slight  and  in- 
definite. G.  A.  Banna.tyne  (Lancet, 
Feb.  23,  1901). 

In  syringomyelia  of  the  psendoacro- 
mcgalic  type,  the  hypertrophic  process 
is  confined  to  the  upper  limbs  and  some- 
times to  a  single  extremity.  It  does  not 
involve  equally  all  the  fingers  of  a  hand. 
The  parts  involved  are  deformed  and 
exhibit  more  or  less  marked  trophic 
changes.  The  symptoms  resulting  from 
the  spinal. cord  lesion  are  easily  recog- 
nized. 

As  for  certain  localised  hypertrophic 
manifestations  (macrodactylia,  macro- 
podia,  hypertrophy  of  a  limb,  or  of  one 
side  of  the  body),  described  by  Virchow 
under  the  name  of  partial  acromegaly, 
they  are  congenital  in  most  instances 
and  bear  no  relationship  to  true  acro- 
megaty. 

PATHOLOGY.— The  dystrophic 
process  in  acromegaly  shows  a  special 
predilection  for  the  supporting  tissues 
derived  from  the  mesoderm  (connect- 
ive tissue,  cartilage,  and  bone),  to  what- 
ever degree  of  differentiation  they  may 
have  attained. 

The  thickening  of  the  integument  is 
due  to  marked  proliferation  of  its  con- 
nective-tissue elements;  the  prolifera- 
tion takes  place  in  each  of  its  various 
layers.  Hyperplasia  in  the  superficial 
stratum  brings  about  hypertrophy  of 
the  papillae,  causing  them  to  appear  as 
pronounced  ridges.  Similar  connective- 
tissue  proliferation  takes  place  in  the 
walls  of  the  sebaceous  and  sweat  glands, 
in  the  sheaths  of  the  hair-follicles,  in 
the  adventitia  of  the  superficial  blood- 


vessels, and  in  the  nerve-sheaths.  These 
vascular  and  nervous  changes  are  not 
without  influence  on  the  trophic  state 
and  functions  of  the  skin.  They  like- 
wise interfere  with  the  nutrition  of  the 
cutaneous  appendages.  The  epidermis 
develops  many  new  layers,  especially  in 
the  zone  of  the  stratum  corneum;  the 
several  varieties  of  hair  become  thick- 
ened and  kinked,  and  the  nails  develop 
longitudinal  striations.  Hypertrophy  of 
the  teeth  has  occasionally  been  noticed 
(Henrot). 

The  connective-tissue  cells  of  the  sub- 
cutaneous panniculus  adiposus  in  some 
cases  become  overloaded  with  fatty  ma- 
terial. To  this  superficial  adipose  de- 
posit is  added,  in  the  syndrome  identi- 
fied by  Frohlich,  a  deep-seated  adipose 
accumulation,  especially  marked  in  the 
neighborhood  of  the  peritoneal  reflec- 
tions. 

Macroglossia  is  due  not  only  to  thick- 
ening of  the  mucous  covering  layer  of 
the  tongue,  but  also  to  abnormal  growth 
of  the  interstitial  connective  tissue.  The 
nasal,  pharyngeal,  laryngeal,  and  tra- 
cheal mucous  membranes  are  likewise 
the  seat  of  marked  proliferation  of  the 
connective-tissue  elements. 

The  alterations  occurring  in  the  fleshy 
portions  of  the  muscles  must  also  be 
attributed  to  changes  of  this  kind. 
Thickening  of  their  sheaths  and  of  the  I 
septa  dividing  them  into  bundles  brings ' 
about  a  marked  increase  in  their  size. 
Microscopically,  proliferation  of  the  nu- 
clei and  atrophy  of  the  contractile  sub- 
stance are  observed.  The  hypertrophic 
process  extends  to  the  tendons,  of  which 
the  inserting  surfaces  become  broader, 
and  to  the  aponeurotic  expansions. 

Among  all  the  changes  which  the  sup- 
porting tissues  undergo,  the  most  char- 
acteristic, as  well  as  the  most  marked, 
are  those  involving  the  skeleton;   they 


314 


ACROMEGALY    (LAUNOIS   AND    CESBRON). 


are  the  result  of  a  disturbance  in  the 
process  of  periosteal  bone  formation. 

They  are  met  with  in  the  bones  hav- 
ing marrow  cavities,  and  are  confined 
to  those  of  the  extremities  and  those  of 
cancellous  structure.  They  are  also 
found  in  those  membranous  bones 
(cranial  bones,  inferior  maxillary  bone) 
which  develop  directly  from  the  con- 
nective tissues,  without  being  preceded 
by  cartilage. 

Whereas  in  adult  life  the  periosteum 
ordinarily  ceases  to  be  productive  ex- 
cept under  certain  experimental  or  trau- 
matic conditions,  of  which  a  detailed 
analysis  was  made  by  Oilier,  in  acro- 
megaly it  is  seen  to  proliferate  and  pro- 
duce increased  thickness  of  the  bones 
by  laying  down  new  osseous  layers. 
Pierre  Marie  and  Marinesco  (Archives 
de  Med.  Exper.  et  d'Anat.,  p.  539, 
1891),  Renaut  and  Duchesneau,  have 
made  studies  of  the  histological  changes 
occurring  in  this  abnormal  type  of  os- 
teogenesis. The  process  is  described  as 
"a  slow  growth  of  certain  bones,  taking 
place  at  the  expense  of  the  periosteal 
bone,  which  is  reduced  to  thin  layers, 
while  the  bony  tissue  of  medullary 
origin  gains  in  prominence,  continues 
to  develop  with,  so  to  speak,  mathemat- 
ical regularity,  and  comes  to  occupy  a 
predominant  position  in  the  structure  of 
the  bone.  On  transverse  section  the  en- 
tire area  is  occupied  by  red  bone-mar- 
row, containing  more  or  less  numerous 
fat-cells.  The  vessel  supplying  each 
medullary  space  is  located  exactly  in 
Its  center  and  appears  in  cross-section. 
,  .  .  At  the  periphery  of  the  bone- 
marrow,  in  the  neighborhood  of  the 
open  areas  corresponding  to  the  giant 
Haversian  spaces  of  cancellous  bone- 
tissue,  the  rows  of  osteoblasts  and  mul- 
tinuclear  cells  which  are  seen  in  rachitic 
bones  are  here  conspicuously  absent." 


Summarizing  the  above,  we  may  state 
that,  whereas  new  layers  are  being 
added  at  the  periphery  of  the  bone,  the 
central  portion  is  undergoing  actual  re- 
sorption by  the  osteoclasts,  the  marrow 
proliferating  to  take  its  place.  Recently 
Presbeanu  (These  de  Paris,  1909)  had 
the  opportunity,  in  a  case  of  acromegaly 
that  died  as  the  result  of  a  fall  causing 
multiple  fractures,  to  note  the  existence 
of  marked  demineralization  of  the 
bones ;  the  proportion  of  ash,  which  nor- 
mally ranges  between  50  and  80  per 
cent.,  had  been  reduced  to  36  per  cent. 
These  chemical  changes  may  well  ac- 
count for  the  weakened  condition  of  the 
skeleton  in  this  disease. 

In  infantile  giants  undergoing  transi- 
tion into  acromegaly,  the  changes  in  the 
bones  coexist  with  an  altogether  abnor- 
mal persistence  of  the  cartilages  uniting 
the  epiphyses  of  long  bones  to  their  di- 
aphyses.  In  these  cases  the  bones, 
while  growing  in  thickness,  also  increase 
in  length,  at  least  for  a  certain  period. 

The  articulating  surfaces  of  the  bones 
become  broader,  and  the  cartilaginous 
tissues  covering  them  spread  out  with- 
out losing  in  depth.  They  may  undergo 
some  slight  alterations  in  structure,  re- 
calling those  seen  in  the  early  stages  of 
certain  arthropathies. 

As  for  the  changes  occurring  in  the 
cardiovascular  system,  though  less 
plainly  evident  than  those  already  dis- 
cussed, they  are,  nevertheless,  well 
marked.  The  thickening  of  the  vessel 
walls  and  cardiac  hypertrophy  are  due 
to  hyperplasia  of  the  connective-tissue 
elements  they  contain.  The  cardiac 
muscular  fibers  may  be  more  or  less  al- 
tered. 

Enlargement  of  the  heart,  either 
simple  or  associated  with  a  myocar- 
ditis, is  the  condition  usually  found 
in  acromegaly.  Sclerosis  of  the  ar- 
teries and  degenerative  lesions  affect- 


Molds  of  the  Upper  Extremities  of  a  Case  of  Acromegaly.     (P.  E.  Launois.) 


ACROMEGALY    (LAUNOIS   AND    CESBRON). 


315 


ing  the  walls  of  the  veins,  with  dila- 
tation and  subsequent  obliteration  of 
their  lumen,  are  constantly  present. 
These  changes  in  the  heart  and  ves- 
sels should  be  considered  as  much  a 
part  of  the  clinical  picture  as  the 
changes  in  the  bones,  and  they  are 
probably  due  to  the  prolonged  hyper- 
tension of  the  vessels,  the  result  of 
hypersecretion  of  the  pituitary  body. 
Phillips  (Med.  Rec,  Feb.  20,  1909). 

The  spleen  and  lymph-nodes  some- 
times appear  sclerosed,  so  greatly  has 
their  connective-iissue  netw^ork  become 
thickened. 

In  a  few  cases  a  more  or  less  general- 
ized condition  of  splanchnomegaly  has 
been  reported,  constituting  a  genuine 
gigantism  of  the  viscera. 

[In  this  connection  the  observations  of 
Linsmayer,  of  Bourneville  and  Regnault 
(Bull,  de  la  Soc.  Anat.  de  Paris,  July  31, 
1896),  and  of  Chauffard  and  Ravaut  (Bull, 
de  la  Soc.  Med.  des  Hop.  de  Paris,  Mar. 
23,  1900)  have  yielded  valuable  informa- 
tion.   Launois  and  Cesbron.] 

The  kidneys,  spleen,  and  pancreas 
had,  in  a  few^  of  these  cases,  doubled  or 
even  tripled  in  size. 

Atrophy  of  certain  viscera,  e.g.,  of  the 
kidney,  has  been  recorded  in  a  few 
cases ;  the  appearance  of  the  renal  cor- 
tex recalled  that  commonly  found  in  in- 
terstitial nephritis. 

In  the  nervous  system  the  connective- 
tissue  proliferation  already  manifested 
in  the  finer  peripheral  divisions  then  ex- 
tends to  the  deeper  branches  of  the 
nerves,  which  present  the  appearance  of 
thick  cords.  The  sympathetic  nerve 
branches,  and  more  especially  the  in- 
ferior cervical  ganglion,  have  been 
found  enlarged  and  sclerosed. 

In  a  case  studied  by  Duchesneau,  the 
peripheral  nerves  showed  changes  due 
to  pressure  exerted  on  the  spinal  roots 
at  the  intervertebral  foramina.  In  that 
of  Sainton  and  State  there  was  bony  in- 


filtration of  the  dura,  with  the  forma- 
tion of  calcareous  deposits  on  its  inner 
surface,  transforming  it,  in  the  dorsal 
and  lumbar  regions,  into  a  veritable 
tube  of  lime. 

The  spinal  cord  has  occasionally  been 
found  the  seat  of  connective-tissue  pro- 
liferation and  localized  or  more  or  less 
widespread  sclerosis. 

In  the  brain,  the  neuroglia,  which  is 
also  one  of  the  group  of  supporting 
tissues,  may  proliferate  more  or  less 
actively. 

The  Hypophysis.  —  Among  the 
changes  taking  place  in  the  intracranial 
structures,  the  most  interesting,  as  well 
as  the  most  important,  are  those  involv- 
ing the  hypophysis. 

Connected  by  a  partially  hollow  stalk 
with  the  base  of  the  brain,  molded  into 
the  sella  turcica,  which  it  almost  com- 
pletely fills,  held  in  position  by  a  dia- 
phragm of  dura  mater  centrally  perfo- 
rated, arid  weighing  on  the  average  0.5 
gram  [7^  grains]  in  adults,  the  hy- 
pophysis has  long  been  considered  an 
ancestral  remnant,  a  rudimentary  organ 
of  no  importance. 

[Modern  histological  researches,  in  par- 
ticular those  of  Comte  (These  de  Lau- 
sanne, 1898),  of  Caselli,  of  Benda  (Berliner 
klin.  Wochenschr.,  No.  52,  1900;  Neurol. 
Centralbl.,  p.  140,  1901,  and  p.  223,  1902; 
Archiv  f.  Psych.,  xxxv,  p.  272,  1901),  of 
Launois  (These  de  la  Faculte  des  Sciences 
de  Paris,  1904),  of  Thaon  (These  de  Paris, 
1908),  of  Gentes  (Bull,  de  la  Station  biolog- 
ique  d'Arcachon,  1907),  of  Joris  ("Contri- 
bution a  I'etude  de  I'hypophyse,"  Memoire 
couronne  public  par  I'Academie  royale  de 
Bruxelles,  xix),  etc.,  have  furnished  an 
insight  into  the  structure  of  its  two  con- 
stituent parts— the  epithelial  lobe  and  the 
neural  lobe.     Launois  and  Cesbron.] 

According  to  one  of  us,  the  anterior 
or  epithelial  lobe  of  the  hypophysis  is 
a  gland  of  branched  tubular  type.  The 
epithelial  tubes  or  cords  of  which  it  is 


316 


ACROMEGALY    (LAUNOIS   AND    CESBRON). 


composed  undergo  anastomosis.  In  the 
spaces  between  them  run  very  broad 
capillary  blood-vessels,  with  very  thin 
endothelial  walls,  which  must  be  con- 
sidered as  the  excretory  ducts.  The 
glandular  cords  are  made  up  of  epithe- 
lial cells  loaded  with  granulations.  In 
view  of  the  different  staining  affinities 
shown  by  the  latter,  the  cellular  ele- 
ments containing  them  may  be  divided 
into  three  classes:  1,  acidophile  cells, 
which   may   be   eosinophiles,    fuchsino- 


X-ray  of  base  of  an  acromeg'alic  cranium,  showingr 
enlargement  of  sella  turcica.  ( Ch.  Jnfroit.) 

philes,  or  aurantiophiles ;  2,  basophile 
cells,  sometimes  called  cyanophiles ;  3, 
chromophobe  cells.  The  protoplasm  of 
these  cells  is  always  acidophile.  It  con- 
tains, except  in  the  case  of  the  young 
acidophilic  forms  and  the  chromo- 
phobes, zymogenic  granulations,  which 
infiltrate  the  epithelial  elements  of  the 
glands.  In  addition  to  their  acidophilic 
property,  the  intracellular  granulations 
possess  in  common  the  property  known 
as  siderophilia. 

The  primordial  cell  of  the  pituitary 
gland,  from  the  morphological  as  well 
as  the  embryological  standpoint,  is  a 
small  eosinophilic  cell  with  compact  nu- 
cleus and  small  protoplasmic  body,  de- 
void of  granulations.  This  cell  develops 


along  two  different  lines  and  produces 
either  an  acidophilic  and  siderophilic  se- 
cretion or  a  basophilic  secretion.  Two 
distinct  series  of  cells,  therefore,  exist 
in  the  hypophysis :  an  eosinophilic  se- 
ries, which  becomes  siderophilic,  and  an 
eosinophilic  series,  which  becomes  baso- 
philic. The  products  elaborated  by 
them  having  been  eliminated  by  a  semi- 
holocrine  process,  the  cells  of  both  series 
become  chromophobic  cells,  which  are 
capable  of  undergoing  regeneration  and 
of  renewing  their  functional  activity. 
The  secretory  product  of  the  hypophy- 
sis is  a  colloid  substance,  giving  reac- 
tions sometimes  acidophilic,  at  other 
times  basophilic,  and  which  presents 
analogous  features  with  the  material 
contained  in  the  alveoli  of  the  thyroid 
gland.  We  have  thought  it  proper  to 
introduce  a  summary  of  this  cytologic 
study,  based  on  our  own  researches,  be- 
lieving that  it  may  serve  as  a  basis  for 
pathological  studies,  the  results  of 
which  thus  far  have  been  indefinite  and 
inconstant. 

On  the  basis  of  facts  discovered  on 
the  autopsy  table,  which  today  usually 
receive  confirmation  from  radiographic 
studies  of  the  skull  during  life,  we  are 
able  to  assert,  as  we  have  already  shown, 
that  hypertrophy  of  the  hypophysis  is 
the  rule  in  acromegaly. 

[We  need  but  call  to  mind  the  statistics 
of  Woods  Hutchinson,  based  on  a  series 
of  48  cases.  In  44  of  these  the  autopsy 
revealed  a  more  or  less  marked  enlarge- 
ment of  the  gland  and  a  corresponding  in- 
crease in  the  size  of  the  sella  turcica.  Of 
the  4  cases  in  which  no  enlargement  was 
found,  3  could  hardly  be  considered  as 
cases  of  true  acromegaly  (those  of  Scarbo, 
of  Friedreich,  and  of  Arnold).  In  the 
fourth,  that  recorded  by  Bonardi,  the  gland 
seemed  morphologically  normal. 

Similarly,  Modena,  out  of  70  cases  with 
autopsies  recorded,  found  hypertrophy  of 
the  hypophysis  in  65.     In  but  5  cases  did 


ACROMEGx\LY    (LAUNOIS   AND    CESBRON). 


317 


Cyanophile 
Series. 


acidosiderophile 
Series. 


Slightlt/  granii  In  r 
cyanophile  cell. 


Markedly  granular 
cyanophile  cell  con- 
taining fat. 


Cyanophile  cell  con- 
taining cyanophilic 
colloid  secretion. 


Primordial  eosinophile  cell  without  granula- 
tions. 


\    Gramilar  eosinophile 
cell. 


^k*\Siderophile    cell  con' 
»'-*'     taining  fat. 


Siderophile  cell  containing 
siderophilic  colloid  secre- 
tion. 


Residual  chromophobe  cell  destined  to  undergo  regen- 
eration. 


The  two  series  of  secreting  cells  found  in  the  hypophysis,  according  to  the 
researches  of  P.  E.  Launois. 


318 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


the  organ  appear  to  be  of  normal  size,  and 
in  only  1  [Labadie-Lagrave  and  Deguy 
(Archives  gen.  de  Med.,  Feb.,  1896)]  did  it 
seem  likewise  normal  in  histological  struc- 
ture. 

Gaussade  and  Laubry  (Archives  de  Med. 
exper.  et  d'Anat.  pathol.,  p.  172,  Mar.,  1909) 
have  more  recently  collected  the  informa- 
tion scattered  in  literature  concerning 
cases  in  which  a  tumor  of  the  hypophysis 
was  not  accompanied  by  acromegaly  or 
osseous  hypertrophy.    Schiister,  in  62  cases 


Tumor  of  the  pituitary  from  the  giant 
Santos.    (Dana.) 


of  tumor  of  the  hypophysis  accompanied 
by  mental  disturbances,  reports  having 
found  acromegaly  but  12  times.  Launois 
AND  Gesbron.] 

We  desire  to  call  attention  to  the  fact 
that  in  a  number  of  these  negative  cases 
the  tumor  did  not  originate  in  the  hy- 
pophysis itself ;  that  this  gland  was 
simply  compressed  or  destroyed,  and 
that  in  a  few  cases  the  histological  de- 
scriptions were  decidedly  lacking  in 
completeness.  We  must  admit,  never- 
theless, that  certain  of  the  facts  at  hand 
leave  room  for  doubt;  which  will  have 
to  be  dispelled  by  future  observations. 


The  gross  features  of  tumors  of  the 
hypophysis  vary.  The  size  ranges  from 
that  of  a  cherry  up  to  a  hen's  egg  or 
mandarin.  The  sella  turcica  varies  sim- 
ilarly in  its  dimensions ;  its  clinoid  proc- 
esses recede  from  one  another,  become 
blunted,  and,  where  an  infiltrating  neo- 
plasm is  present,  sometimes  disappear 
entirely,  together  with  the  bony  parti- 
tions they  surmount. 

The  tumor  not  infrequently  projects 
beyond  the  limits  of  the  bony  fossa,  not- 
withstanding the  increased  size  of  the 
latter;  it  bulges  toward  and  indents  the 
lower  surface  of  the  cerebrum,  and  may 
even  infiltrate  it  to  a  considerable  depth. 

In  color  the  growth  is  usually  gray- 
ish, sometimes  yellowish ;  its  external 
surface,  often  granular  in  appearance, 
may  be  dotted  with  small,  reddish  areas, 
representing  dilated  vessels  or  even  true 
hemorrhagic  foci.  In  consistency  it  is 
soft  and  more  or  less  friable.  On  com- 
plete transverse  section  more  or  less 
extensive  pockets  of  colloid  material 
having  a  gelatinous  appearance  may  be 
revealed. 

These  general  features,  which  belong 
more  particularly  to  tumors  of  epithe- 
lial origin,  may  be  variously  modified 
according  to  the  type  of  neoplasm  pres- 
ent, which  may  be  sarcomatous,  angio- 
matous, etc. 

The  minute  structure  of  tumors  of 
the  hypophysis  has  been  variously  in- 
terpreted. The  diversity  of  the  descrip- 
tions given  of  it  results  chiefly,  if  not 
entirely,  from  the  uncertainty  which 
prevailed  until  within  the  last  few  years 
as  to  the  normal  structure  of  the  gland. 

It  seems  to  have  been  shown,  how- 
ever, that,  in  a  number  of  the  cases  re- 
ported, the  tumor  was  epithelial  in 
origin.  From  the  57  cases  collected  by 
him,  Parona  has  obtained  the  following 
percentages : — 


ACROMEGALY    (LAUNOIS    AND    CESBRON).  319 

Adenosarcoma 45  per  cent.  tary    which,    while    normal    in    macro- 
Adenoma  26    "        "  scopic  appearance,  contained  numerous 

Sarcoma 19.4"        "  ,  ,  ....         ,, 

Angioma 3.4  "       "  '^'"^"^  chromophilic  cells. 

These  figures,  together  with  similar  [Similarly,  Gilbert  Ballet  and'Laignel- 

statistics  already  published,   should  be  Lavastine    (Nouv.    Iconogr.    de   la   Salpe- 

taken  with  some  reserve,  and  we  must  *"^'';.  P"   ^'^\  ^^°^^   ^^^^  "°*"^  '"  ^<=''°- 

..     -TT  ,1  ,•  megalics  at  the  outset  a  glandular  hyper- 

recognize,  with  Hanau,  that  the  condi-  pj^^^^  j^  ^^^^^^  ^f  development.    L.^unois 

tion  of  diffuse  hypertrophy  of  the  pitui-  and  Cesbron.] 


Tumor  of  the  pituitary  body  extendinginto  the  right  lateral  ventricle, 
(P.  E.  Launois.) 


tary  bears  a  marked  resemblance  to  sar- 
coma. 

A  few  of  the  descriptions,  however, 
embody  cytological  details  sufficiently 
definite  to  be  of  value.  Among  them 
may  be  mentioned  the  observations  of 
Benda,  who  found,  in  three  instances, 
that  the  hypertrophy  was  due  to  pro- 
liferation of  the  chromophile  cells,  i.e., 
the  functionally  active  elements  of  the 
gland.  In  a  fourth  case,  the  neoplasm 
was  undergoing  regression.  Hyperpla- 
sia of  the  same  cells  has  hkewise  been 
observed  three  times  by  Vassale.  Lewis, 
in  an  acromegalic  case  which  succumbed 
to  cerebral  hemorrhage  soon  after  the 
onset  of  the  dystrophy,  found  a  pitui- 


Case  of  acromegaly  of  ten  years* 
duration.  No  enlargement  of  the  hy- 
pophysis was  found  at  autopsy,  but,  in- 
stead, a  tumor  composed  of  tissue 
identical  with  the  chromophile  cells  of 
the  anterior  lobe  of  the  hypophysis,  and 
occupying  the  body  of  the  sphenoid 
bone,  immediately  beneath  the  sella 
turcica.  Supports  theory  of  Tamburini 
and  Benda  that  acromegaly  is  caused  by 
a  hypersecretion  of  the  hypophysis. 
Erdheim  (Ziegler's  Beitrage,  Bd.  Ixiv, 
S.  233,  1909). 

Enlargement  of  the  hypophysis  may 
also  result  from  exaggerated  growth  of 
its  connective-tissue  network.  Under 
such  conditions  the  stage  of  hyperplasia 
of  the  organ,  associated  with  expansion 
of  the  sella  turcica,  may  be  followed  by 


320 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


a  stage  of  sclerotic  atrophy.  The  en- 
larged bony  cavity  does  not  resume  its 
former  size  and  appears  too  capacious 
for  the  gland  inclosed  in  it.  This  condi- 
tion was  found  in  a  case  of  Huchard,  in 
which  the  autopsy  was  performed  by 
one  of  us. 

Instead  of  being  generalized  through- 
out the  glandular  parenchyma,  the  neo- 


to  us  appears  premature,  cannot,  at 
present,  be  unreservedly  accepted,  for 
a  few  cases  have  been  seen  in  which  the 
hypophyseal  lesion  was  not  accompa- 
nied by  any  dystrophic  disturbance. 

In  acromegalic  gigantism  tumors  of 
the  hypophysis  are  more  constantly 
present  than  in  simple  acromegaly.  We 
have  already  stated,  indeed,  that  in  the 


Celliilar  characteristics  of  a  tumor  of  the  pituitary.    (P.  E.  Launois. ) 


plastic  process  may  be  localized  and  ap- 
pear in  the  form  of  more  or  less  volum- 
inous masses  (partial  adenomas,  cysts), 
reaching  a  variable  size  [Widal,  Roy, 
and  Froin  (Revue  de  Med.,  Apr.  10, 
1906)]. 

From  a  general  review  of  the  facts 
yielded  by  recent  investigations,  the  tend- 
ency has  arisen  to  accept  the  conclu- 
sion that  the  hyperplastic  condition  of 
the  hypophysis  observed  in  acromegaly 
is  dependent  upon  an  increase  in  the 
number  and  size  and  an  exaggerated 
functional  activity  of  the  chromophilic 
cells.     This  assertion,  however,  which 


former  condition  they  have  never  been 
found  wanting.  As  for  their  histolog- 
ical structure,  the  same  uncertainty  pre- 
vails. 

To  complete  this  study,  we  shall  men- 
tion the  alterations  which  the  other 
ductless  glands  may  undergo  in  acro- 
megaly : — 

With  reference  to  the  thyroid,  Hins- 
dale, in  a  series  of  .36  cases  collected 
from  the  literature,  found  h)^pertrophy 
13  times,  atrophy  11  times,  while  in  12 
cases  the  gland  appeared  to  be  normal. 

[According  to  Furnivall  (Pathol.  Soc.  of 
London,  Nov.  2,  1897),  the  thyroid  seemed 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


321 


normal  in  only  5  out  of  24  cases  of  acro- 
megaly. Wc  lia\  c  mirselves  seen  the  dys- 
trophy coexisting  with  simple  goiter;  Lan- 
cercaux  and  Murray  (Edin.  Med.  Jour., 
1897),  with  exophthalmic  goiter.     Launois 

AND   CeSBRON.] 

Klebs,  Massalongo,  and  Mosse  have 
reported  hypertrophy  or  regeneration  of 
the  thymus  gland.  Most  observers  have 
failed  to  inquire  into  the  condition  of 
the  adrenals.  Their  study  might  prove 
fruitful,  in  view  of  the  opinion  of  Sa- 
jous  that  these  organs  take  an  active 
part  in  the  morbid  process. 

PATHOGENESIS.— According  to 
Klebs,  who  had  witnessed  persistence  of 
the  thymus  in  a  case  of  acromegaly,  the 
affection  is  due  to  an  unusual  state  of  de- 
velopment of  the  vascular  system,  and 
results  from  an  angiomatous  condition 
of  the  thymus.  According  to  this  view, 
the  thymus  produces  endothelial  ele- 
ments which,  swarming  through  the  ves- 
sels, assume  the  role  of  formative  cells 
in  the  production  of  fresh  vessels.  Thus 
there  would  result  an  increase  in  the 
number  of  vascular  channels,  and,  in 
consequence,  hypernutrition  and  aug- 
mentation in  size  of  the  terminal  por- 
tions of  the  body,  i.e.,  of  those  regions 
of  the  organism  in  which  the  flow  of 
blood  slackens  its  speed.  This  power 
to  form  new  vessels,  however,  which 
he  attributes  to  the  thymus,  is  as  yet 
lacking  in  proof. 

Massalongo  has  taken  up  Klebs's  the- 
ory and  modified  it.  He  believes  acro- 
megaly to  be  due  to  persistence  of  the 
functions  of  the  thymus  and  the  hypoph- 
ysis— organs  which  play  an  impor- 
tant part  during  fetal  life.  Normally, 
these  glands  undergo  retrogression,  he 
states,  at  the  age  when  growth  ceases, 
i.e.,  between  the  20th  and  25th  years. 
If  their  functions  continue  after  that 
age  has  been  passed,  acromegaly  results. 


Freund  and  Verstraeten  attribute  the 
dystrophy  to  a  reversal  in  the  normal 
order  of  events  occurring  in  sexual  de- 
velopment.    "In  a  certain  number  of 
individuals,"  writes  Freund,  ''the  ordi- 
nary mode  of  development  is  disturbed. 
Either  it  lags  behind  the  norm,  or  else 
it  advances  beyond  the  norm,  both  in 
time  and    in   space    [i.e.,  morphologic- 
ally] ;  the  malformations  which  result 
go  hand-in-hand  with  the  disturbance 
in    the    development    of    puberty,  and 
later,  too,  of  the  sexual  functions."    It 
is  certain  that  the  development  of  the 
genital  apparatus  is  not  without  influ- 
ence on  that  of  the  osseous  system,  and 
one  of  us,  in  a  series  of  communica- 
tions, has  described  the  alterations  pro- 
duced in  the  bones  by  congenital  atro- 
phy of  the  testicles,  of  the  ovaries,  and 
by  castration  before  puberty.    Now,  the 
frequency  with  which   disturbances  of 
the  genital  .functions  are  associated  with 
acromegaly  has  long  been  noticed.    But 
how  is  the  influence  they  may  exert  on 
the  growth  of  the  skeleton  to  be  ex- 
plained ?    Perhaps  by  their  suppression, 
diminution,  or  modification  of  a  secre- 
tory   product    having    as    its    purpose, 
a''    suggested    by    Sajous,    to    activate 
the  oxidation  of  phosphorus-containing 
substances. 

[Schiff,  Ruttle,  and  Duchesneau  have  re- 
ported an  increased  elimination  of  phos- 
phorus; but  Moraczewski  (Zeitschr.  f. 
klin.  Med.,  xliii,  Nos.  3  and  4,  1901),  Tansk 
and  Vas,  and  Parhon  ("Contributiuni  la 
studiul  schimburilor  nutritive  in  acromeg- 
alie,"  Bucuresti,  1903;  Revista  Stiintelor 
Medicale,  No.  2,  1905),  on  the  other  hand, 
have  found  it  to  be  retained  in  the  organ- 
ism.   Launois  and  Cesbron.] 

In  short,  the  development  of  the  geni- 
tal functions  having  some  influence  on 
that  of  the  skeleton  in  general,  disturb- 
ances in  these  functions  may  be  factors 
in  the   production  of  acromegaly,  but 


1—21 


322 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


they  do  not  appear  to  be  sufficient  to 
bring  on  the  dystrophy  of  themselves. 

In  the  opinion  of  Reckhnghausen  and 
Holschewnikow,  acromegaly  is  merely 
a  trophoneurotic  affection,  dependent 
upon  changes  in  the  central  and  pe- 
ripheral nervous  system.  Disturbances 
involving  the  vasomotor  nerves  would, 
according  to  this  view,  lead  to  over- 
nutrition  and  hypertrophy  of  the  ex- 
tremities. There  is  nothing  to  indicate, 
however,  that  the  nervous  changes  in 
this  dystrophy  are  primary.  The  case  on 
which  these  two  observers  based  their 
opinion  was  one  of  syringomyelia. 

Pierre  Marie  looks  upon  acromegaly 
as  "a  kind  of  systematized  dystrophy, 
occupying  in  the  nosological  scale  a  po- 
sition about  corresponding  with  that  of 
myxedema,  and  bearing  to  an  organ  of 
trophic  function  (the  hypophysis)  as 
yet  unknown  relations  similar  to  those 
which  unite  myxedema  and  cachexia 
strumipriva  to  certain  lesions  and  re- 
moval of  the  thyroid  gland." 

As  this  quotation  shows,  it  was  the 
sponsor  of  acromegaly  himself  who  was 
the  first  to  suspect  the  functional  role 
of  the  hypophysis,  "that  enigmatic  or- 
gan," as  Van  Gehuchten  termed  it  not 
so  many  years  ago. 

In  the  preceding  pages  we  have  suffi- 
ciently dwelt  upon  the  frequency,  and 
even  constancy,  with  which  hypertrophy 
of  the  hypophysis,  especially  of  epithe- 
hal  origin  (adenoma),  is  present  in 
acromegaly.  We  pointed  out,  likewise, 
a  condition  which  is  daily  receiving  con- 
firmation from  X-ray  studies,  viz. :  that, 
whatever  be  the  mode  of  progression  of 
the  dystrophy,  whether  it  take  expres- 
sion in  its  sthenic  phase  as  the  pure 
acromegalic  type  of  Pierre  Marie,  or 
the  lipomatous  type  of  FrohHch,  there 
is  present  in  most  cases  enlargement  of 
the  sella  turcica,  which  serves  to  indi- 


cate hypertrophy  of  the  pituitary  body. 
In  view  of  these  facts,  while  recognizing 
to  their  full  value  the  negative  cases  so 
far  recorded,  we  are  completely  in  favor 
of  the  hypophyseal  theory. 

Having  reached  this  conclusion,  we 
still  have  to  solve  two  other  phases  of 
the  problem,  viz. :  to  ascertain  the  na- 
ture and  mode  of  action  of  the  disor- 
ders affecting  the  function  of  the  hy- 
pophysis, and  to  find  out  whether  these 
disorders  are  sufficient  in  themselves,  or 
whether  it  is  not  necessary  to  invoke 
the  synergistic  functions  of  the  other 
ductless  glands  as  participating  in  the 
disturbance. 

The  experiments  of  physiologists,  an 
excellent  analysis  of  which  has  been 
given  by  Paulesco  (L'hypophyse  ducer- 
veau,  Paris,  1908),  have  yielded,  it  must 
be  said,  no  definite  results.  Practised 
upon  young  or  old  animals,  removal  of 
the  hypophysis  produced  no  skeletal  dis- 
orders nor  acromegalic  manifestations. 
This  dearth  of  results  is  not  surprising 
when  we  consider,  on  the  one  hand,  the 
comparatively  short  period  of  survival 
of  the  experimental  animals,  and,  on 
the  other,  the  serious  traumatism  to 
which  they  had  been  subjected  in  the 
operations.  Of  greater  weight,  as  we 
have  already  emphasized,  are  the  data 
afforded  by  the  clinicopathological 
method.  It  is  on  the  basis  of  these  data 
that  investigators  have  sought  to  ascer- 
tain the  functions  of  the  hypophysis, 
and,  in  particular,  its  trophic  role. 

Some  authors,  among  them  Tansk 
and  Vas,  and  Parhon,  consider  acro- 
megaly to  be  the  result  of  excessive 
functionation  on  the  part  of  the  pitui- 
tary— a  genuine  hyperhypophysia.  Ac- 
cording to  others,  the  functional  role  of 
the  gland  is  to  destroy  substances  toxic 
to  the  nervous  system.  The  accumula- 
tion of  these  substances,  in  the  presence 


ACROMEGALY    (LAUNOIS   AND    CESBRON). 


323 


of  functional  disturbance  of  the  hy- 
pophysis, would  produce, because  of  spe- 
cial predisposition,  a  continual  state  of 
irritation,  resulting  in  hyperplastic 
changes  in  the  bony  and  other  support- 
ing tissues,  primarily  and  chiefly  notice- 
able in  the  extremities.  The  acromeg- 
alic deformities  would  be  an  expression 
of  functional  insufficiency  of  the  organ, 
or  Jiypohypophysia. 

The  above  hypotheses  were  those 
most  generally  accepted  when  Hochen- 
egg  published  the  results  of  his  opera- 
tions of  hypophysectomy,  which  will  be 
described  below.  The  progressive  re- 
trogression of  the  manifestations  of 
acromegaly  witnessed  after  excision  of 
hypophyseal  tumors  affords  an  argu- 
ment of  the  first  importance  in  favor  of 
the  theory  of  glandular  hypersecretion. 
Future  observations  will  soon  bring  fur- 
ther confirmatory  evidence. 

The  facts  recorded  by  Hochenegg 
have  also  lent  considerable  support  to 
the  doctrine  of  the  synergistic  func- 
tional relationship  existing  between  the 
ductless  glands.  In  one  of  his  cases, 
menstruation,  which  had  long  since 
been  arrested,  returned  and  was  main- 
tained at  regular  intervals.  In  2  cases 
removal  of  the  hypophysis  was  followed 
by  hypertrophy  of  the  thyroid.  We 
have  already  stated  that  at  the  autopsy 
of  acromegalics  hyperplasia  of  one  or 
more  ductless  glands  is  frequently 
found.  Furthermore,  it  is  well  known 
that  the  sexual  glands  exert  a  distinct 
influence  on  the  osteogenetic  activities  of 
the  connecting  cartilages,  and  that  thy- 
roid extract  is  possessed  of  an  analo- 
gous action.  Caselli  has  expressed  his 
belief  in  the  identity  of  the  functions  of 
the  hypophysis  and  thyroid,  basing  his 
opinion  on  the  experimental  observation 
that  removal  of  the  hypophysis  acts  on 
tetany   parathyreopriva    in    the     same 


manner  as  does  removal  of  the  thyroid. 
This  functional  identity,  as  Souques 
(" Acromegalic"  in  "Traite  deMedccine" 
of  Charcot  and  Uouchard,  2d  ed.,  vol.  x, 
p.  490)  terms  it,  or,  better,  this  func- 
tional analogy,  would  furnish  an  ex- 
planation for  the  power  of  mutual  sub- 
stitution of  function  exhibited  by  these 
glands  under  pathological  conditions. 

It  was  through  surgery,  practised  for 
curative  purposes,  that  the  functions  of 
the  thyroid  were  revealed  to  us ;  it  is 
through  surgery  that  today  the  role  of 
the  hypophysis  is  being  disclosed.  It  is 
to  surgery,  again,  that  we  shall  in  the 
future  be  indebted  for  the  acquisition  of 
positive  data  which  will  enable  us  to 
solve  the  absorbing  problem  concerning 
the  synergistic  functional  relationship 
of  the  ductless  glands. 

The  craniopharyngeal  canal,  which 
passes  down  from  the  floor  of  the  sella 
turcica  through  the  basisphenoid  into 
the  nasal  pharynx,  normally  becomes 
obliterated  in  the  fetus  at  the  begin- 
ning of  the  third  month.  In  4829  skulls 
it  was  noted  by  le  Double  to  be  per- 
sisting in  only  10,  about  0.2  per  cent. 
Schlaginhaufen  observed  it,  on  the 
other  hand,  in  40  per  cent,  of  apes' 
skulls  examined.  The  interesting  fact 
now  comes  to  light  that  Dr.  Ettore  Levi, 
of  Florence,  has  found  it  persisting  in 
the  skulls  of  two  acromegalics  which 
he  has  had  the  opportunity  of  observ- 
ing, and  he  describes  the  condition  in 
the  Revue  neurologique  for  May  15th. 
In  one,  situated  mesially  and  at  the 
junction  of  the  anterior  and  middle 
third  of  the  floor  of  the  sella  turcica, 
was  a  round  depression  6  mm.  in 
diameter  and  6j/^  mm.  deep ;  at  the 
bottom  of  this  was  a  small,  round  open- 
ing which  communicated  by  a  canal  9 
mm.  long  through  the  basisphenoid  with 
the  nasal  pharynx,  entering  the  latter 
at  a  point  5  mm.  from  the  posterior 
margin  of  the  left  wing  of  the  vomer, 
and  allowing  the  passage  of  a  seeker 
1  mm.  in  diameter.  In  the  second  case 
a    canal    in    almost    exactly    the    same 


324 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


site  and  with  the  same  course  was 
found.  In  this  connection  it  is  instruct- 
ive that  in  the  skull  of  the  Irish  giant 
Magrath,  described  by  Professor  Cun- 
ningham,  an   elliptical   perforation   was 


is  called  for,  as  it  is  quite  conceivable 
that  an  abnormality  of  this  nature  has 
escaped  observation.  The  light  which  it 
may  throw  on  the  hypophyseal  theory  of 
acromegaly   may  be   considerable.     Re- 


Vertical  rhinotomy  by  means  of  bilateral  osteotomy;  Ollier's  method.    {R.  Proust.) 


noted  in  the  floor  of  the  sella  turcica 
communicating  directly  with  the  nasal 
pharynx,  the  lower  end  of  it  being 
partly  covered  by  the  enlarged  wing  of 
the  vomer.  A  re-examination  of  acro- 
megalic  crania   in  view   of  these   facts 


cent  researches  have  conclusively  shown 
the  existence  of  pituitary  tissue  in  the 
vault  of  the  nasal  pharynx,  deep  in  the 
soft  tissues  lining  the  vault,  an  acces- 
sory pharyngeal  hypophysis  identical  in 
structure  with  the  glandular  part  of  the 


ACROMEGALY    (LAUNOIS    AND    CESBRON). 


325 


cranial  hypophysis  and  of  normal  and 
constant  occnrrence.  Its  pathology  is 
vmknown,  and  what  relation  it  may  bear 
to  those  cases  of  acromegaly  without 
obvious   lesions  of  the  pituitary  gland, 


TREATMENT.— The  treatment  of 
acromegaly  necessarily  remained,  for  a 
long  time,  purely  symptomatic,  and  was 
limited  to  combating  the  most  distress- 


Openingr  of  the  frontal  sinus  after  deflecting  thie  nose.    (R.  Proust.) 


and  those  other  cases  of  lesion  of  the 
pituitary  without  acromegalic  symp- 
toms, is  equally  unknown.  Data  such 
as  these  suggest  an  interesting  line  of 
research  for  subsequent  investigators. 
Editorial   (Lancet,  June  5,  1909). 


ing  manifestations,  such  as  pain  and  in- 
somnia. Agents  modifying  general  nu- 
trition, such  as  iodine  and  arsenic 
(Campbell),  were  then  brought  into 
use.  Iron  in  large  doses  and  hot  baths 


326 


ACROMEGALY    (LAUNOIS  AND   CESBRON). 


were  said  to  have  given  distinct  relief 
in  a  case  under  the  care  of  Brissaud. 
Schwartz     claimed    to    have   obtained 


tried  thyroid  treatment  without  suc- 
cess, though  Lyman  Greene  claimed 
good  results  with  it.     Napier  admin- 


Approach  to  the  sphenoid  after  resecting  the  ethmoid  and  clearing 
the  nasal  passages.    (B.  Proust.) 


beneficial    effects    from    the    use    of 
ergot. 

As  a  corollary  to  the  discoveries  of 
Brown-Sequard,  opotherapic  medica- 
tion was  resorted  to,    Warda  and  Pirie 


istered  powdered  ovary  to  an  acrome- 
galic woman  without  benefit.  Kuh, 
using  pituitary  substance,  and  Favor- 
sky,  using  Poehl's  opohypophysine, 
noted    distinct    improvement    in    the 


ACROMEGALY    (LAUNOIS   AND    CESBRON). 


327 


subjective,    and    even    the    objective,  have  been  led  to  the  conclusion  that  they 

symptoms.     The  latter  ol)server  was  are  entirely  ineffective. 
able    to    continue    the    administration  In  view  of  these  unsuccessful  efforts 

of  hypophysine  in  daily  doses  of  0.05  on  the  part  of  medicine,  the  surgeons, 


Opening  the  sphenoidal  sinus,  of  which  the  median  cell  is  visible.    {R.  Proust.) 


to  0.06  Gm.  (^4  to  1  grain)  for  fifteen 
months,  without  untoward  effects.  For 
our  part,  we  have  utilized  the  various 
animal  preparations  in  a  systematic 
manner  and  for  extended  periods,  and 


emboldened  by  the  increasing  safety  at- 
tending their  operations,  were  not  afraid 
to  attempt  the  removal  of  the  hy- 
pophysis. The  anatomical  situation  of 
the  sfland  seemed  to  make  the  access 


328 


ACROMEGALY    (LAUNOIS   AND    CESBRON). 


to  it  well-nigh  impossible.  Never- 
theless, encouraged  by  the  results 
obtained  by  physiologists,  and  hav- 
ing    gained     additional     information 


and  on  November  16,  1907,  Schlosser 
performed  the  operation  of  removing 
a  tumor  of  the  hypophysis  from  a  living 
person. 


rrephining  the  posterior  wall  of  the  sinus.    The  pituitary,  marked  with  a  white  cross, 
can  be  seen  in  its  dorsal  sheath.    (R,  Proust.) 


through  researches  on  the  cadaver, 
the  operators  ascertained  the  avenues 
of  entrance  which  would  permit  of 
their    reaching    the    pituitary    gland, 


In  theory,  the  hypophysis  may  be 
reached,  according  to  Toupet,  either  by 
an  intracranial  or  by  an  extracranial 
route.    Those  who  favor  the  intracranial 


ACROMEGALY    (LAUNOIS   AND    CESBRON). 


329 


method  advance  as  their  chief  argument 
the  less  danger  of  infection  to  which  the 
I^atient  is  subjected,  and  propose  either 
the  frontal  route  (Krause,  KiHani)  or 
the  temporal  route,  already  employed  in 
their  experiments  by  Caselli  and  Hors- 
ley  (Brit.  Med.  Jour.,  Aug.  25,  1906). 
The  supporters  of  the  extracranial  route  " 
are  the  more  numerous  at  the  present 
time.  Against  the  former  method  they 
.raise  the  objections  of  operative  dififi- 
culty,  severity  of  operative  interference, 
and  the  great  ease  with  which  a  com- 
munication may  accidentally  be  estab- 
lished between  the  cavity  of  the  sella 
turcica  and  the  sphenoid  sinus,  of  which 
the  thin  and  fissured  walls,  in  the  pres- 
ence of  tumor  of  the  hypophysis,  may 
yield  to  the  slightest  touch.  According 
to  these  observers,  the  possibility  of 
such  a  commmiication  would  greatly  re- 
duce the  chances  of  performing  an  asep- 
tic operation  by  the  intracranial  route. 
Moreover,  the  extracranial  operation  in- 
duces but  a  minimal  degree  of  shock, 
and  is  comparatively  easy  in  technique ; 
it  does  not,  however,  exclude  the 
chances  of  infection. 

The  intracranial  method  is  danger- 
ous, uncertain,  and  difficult,  while  the 
oral  route  gives  but  a  limited  operative 
field  and  is  almost  sure  to  be  fol- 
lowed by  infection  owing  to  connection 
with  mouth.  Hecht  (Jour,  of  Nerv. 
and  Ment.  Dis.,  Nov.,  1909). 

We  cannot  here  enter  into  detail  con- 
cerning all  the  proposed  technical  meth- 
ods of  reaching  the  sella  turcica  through 
the  sphenoid  sinus.  According  to  their 
respective  temperaments,  surgeons  have 
planned  either  sweeping  and  broadly 
mutilating  operative  procedures  or  else 
more  economical  methods.  These  pro- 
cedures may,  in  their  main  features,  be 
reduced  to  four,  as  follows:  1.  The 
simple  nasal  route,  practically  the  only 


one  which  has  been  employed  in  man. 
2.  The  nasal  route  combined  with  more 
or  less  extensive  resections  of  the  su- 
perior maxilla  and  the  inner  wall  of  the 
orbit,  even  to  sacrificing  completely  an 
eye  already  functionally  lost  (Schlos- 
ser).  3,  The  buccal  route  of  Gussen- 
baum,  with  resection  of  the  hard  palate, 
advocated  by  Konig  (Berliner  klin. 
Wochenschr.,  No.  46,  p.  1040,  1900). 
4.  Transverse  and  median  suprahyoid 
pharyngotomy,  proposed  by  Loewe 
(ibid.,  Feb.  17,  p.  378,  and  Feb.  24,  p. 
422,  1908).  ^ 

Of  all  these  methods,  the  simple  nasal 
route  is  the  one  which  has  been  used 
almost  exclusively,  with  slight  varia- 
tions in  technique,  on  the  living  subject. 
Horsley  and  McArthur  alone  seem  to 
have  employed  the  temporal  intracranial 
route. 

With  the  omission  of  a  few  details, 
the  operative  technique  may  be  sum- 
marized as  follows  :  Temporary  resec- 
tion of  the  nose,  which  is  reflected  later- 
ally above  and  below;  resection,  osteo- 
plastic if  desired,  of  the  anterior  wall 
of  the  frontal  sinus;  excision  of  the 
vomer  and  of  the  nasal  septum  to  its 
insertion  posteriorly,  which  is  preserved 
as  a  landmark,  showing  the  median  line ; 
removal  of  all  the  ethmoid  air-cells  and 
of  the  turbinated  bones,  to  permit  of 
seeing  and  opening  into  the  sphenoid 
sinus.  The  sinus  having  been  entered, 
the  next  step  is  to  make  an  opening  at 
the  bottom  of  the  sella  turcica,  the  an- 
terior wall  of  which  bulges  forward. 
The  dura  mater  is  then  incised.  The 
tumor  is  removed  piecemeal  by  means 
of  the  curette.  (The  tumors  hitherto 
removed  have  generally  been  very  soft, 
sometimes  cystic,  as  inEiselsberg's  case, 
and  their  excision  presented  no  difii- 
culty.)  The  cavity  of  the  sella  turcica 
is  then  drained  by  means  of  a  rubber 


330 


ACROMEGALY    (LAUNOIS   AND    CESBRON). 


tube  which  passes  out  through  the  nasal 
f ossffi ;  the  latter  are  packed,  and,  as  a 
final  step,  the  nose,  temporarily  drawn 
aside,  is  put  back  in  place. 

This  operation  is  accompanied  by 
marked  bloody  oozing,  which  yields  rap- 
idly, however,  to  packing  with  adrenalin 
solution  in   1  :  1000  strength,  and  gen- 

Ohiasm. 


and  whose  history  was  later  reported 
in  extenso  by  Stumm,  was  a  young  lady, 
31  years  of  age,  in  whom  the  initial  dys- 
trophic manifestations  had  appeared  at 
about  the  25th  year  and  soon  become 
fully  developed.  The  operation  was  in- 
dicated because  of  the  severity  of  her 
headache    and   visual    disturbances.     It 


Optic  nervi. 


Olfactory  bulb. 


Inferior   wall   of 
sphenoidal  sinus. 


Pituitary  body. 


Relations  of  pituitary  body,  as  exhibited  in  the  nasal  route  of  operative  access,  with 
additional  removal  of  bony  floor  of  anterior  cerebral  fossa.     (Proust.) 


erally  ceases  at  the  end  of  fifteen  min- 
utes. 

Successful  cases  of  hypophysectomy 
are  of  interest aiot  only  from  the  stand- 
point of  the  treatment  of  acromegaly, 
but  also  from  that  of  its  pathogenesis. 
With  .respect  to  the  latter,  they  possess 
the  ■  same  value  as  true  experimental 
studies,  and  it  will  be  worth  while  here 
to  give  a  resume  of  the  first  two  cases 
operated  by  Hochenegg. 

The  first  patient,  presented  before  the 
German  Congress  of  Surgery  in  1908, 


was  carried  out  by  the  nasal  route.  No 
untoward  after-effects  appeared,  and 
immediate  results  were  obtained.  Upon 
awakening  the  subject  was  already  re- 
lieved of  the  intolerable  headaches 
which  had  made  her  life  miserable. 
Vision  rapidly  improved.  A  more  re- 
markable event  was  further  witnessed 
in  that,  on  the  fifth  day,  the  symptoms 
of  acromegaly  began  to  disappear.  The 
patient  regained  the  ability  to  close  her 
mouth  completely,  which  she  had  been 
unable  to  do  before.     Her  tongue  and 


ACROMEGALY    (LAUNOIS   AND   CESBRON). 


331 


nose  soon  after  began  to  decrease  in 
size.  A  similar  change  was  observed  in 
her  feet  aiul  hands :  their  thminntion  in 
bulk  was  so  marked  that,  on  leaving  the 
hospital,  she  was  obliged  to  wear  three 
pairs  of  stockings  in  order  to  make  use 
of  her  shoes,  and  that  her  fingers  and 
wrists  literally  floated  around  in  the 
gloves  she  had  worn  before  the  opera- 
tion. The  change  in  her  appearance  was 
such  that  her  family  had  difficulty  in 
recognizing  her.  We  may  add  that  her 
menstruation,  long  since  arrested,  re- 
sumed its  usual  regular  course,  and  that 
in  August,  1908,  a  parenchymatous 
goiter  appeared  in  her  neck. 

The  second  case  operated  by  Hoch- 
enegg  appeared  as  though  modeled  after 
the  first.  The  patient  was  a  woman  of 
34,  in  whom  the  disease,  dating  back 
ten  years,  had  produced  the  most  typ- 
ical dystrophic  changes,  and  was  asso- 
ciated with  amenorrhea,  headache,  and 
disordered  vision.  Excessive  hairy 
growth  and  alterations  in  her  voice  gave 
her  a  peculiar  masculinity.  The  opera- 
tion w^as  carried  out  with  the  same  tech- 
nique as  before  and  was  likewise 
crowned  with  success.  At  the  end  of  a 
week  the  headache  had  almost  com- 
pletely disappeared.  The  extremities 
diminished  in  size  to  such  an  extent  that 
three  months  after  the  operation,  when 
Exner  presented  the  patient  before  the 
Medical  Society  of  Vienna,  the  third 
toe  measured  ^  cm.  less  in  circumfer- 
ence, and  the  middle  finger  }^  cm. 
While  the  menstrual  periods  did  not  re- 
appear, the  hairy  appendages  resumed 
their  normal  state,  and,  as  in  the  first 
patient,  the  thyroid  gland  increased  in 
volume ;  a  growth  the  size  of  a  walnut 
developed  from  the  isthmus. 

Different  measures  should  be  adopted 
under  different  circumstances:  (1) 
"comparatively  small  tumors  in  the  sella 


turcica  covered  with  a  tent  of  dura 
mater  can  be  removed  completely  by 
the  nasal  route ;  (2)  growths  growing 
endocranially,  but  filling  the  sella  tur- 
cica, can  be  removed  in  part  to  relieve 
the  pressure  symptoms,  though  not  the 
acromegaly;  (3)  endocranial  growths, 
removal  of  which  can  only  prove  harm- 
ful. Hochenegg  (Deut.  Zeit.  f.  Chir., 
Bd.  c,  S.  317,  1909). 

Confirmation  of  Paulesco's  observa- 
tion that  simple  division  of  the  stalk 
of  the  pituitary  is  as  fatal  a  procedure 
as  removal  of  the  latter  organ  also, 
and  also  of  the  view  that  the  latter 
procedure  in  animals  is  invariably  fol- 
lowed by  death  within  a  few  days. 
This  fatal  result  is  evidently  due  to  re- 
moval of  anterior  or  epithelial  lobe, 
since  removal  of  the  posterior  or  neural 
lobe  is  followed  by  no  characteristic 
symptom.  Cushing  and  Redford  (Johns 
Hopkins  Hosp.  Bull.,  April,   1909). 

Removal  of  part  of  the  pituitary  for 
the  relief  of  acromegaly  by  the  trans- 
sphenoidal route.  The  patient  was  a 
typical  "case  of  acromegaly,  with  partial 
blindness  and  epileptic  crises.  A  tumor 
of  the  hypophysis  was  diagnosticated, 
and  operation  was  done  by  opening  the 
nose,  passing  through  ethmoidal  and 
sphenoidal  cells  into  the  sella  turcica, 
and  the  removal  of  a  considerable 
amount  of  tissue  from  the  hypophysis. 
The  patient  lived  some  six  weeks  after 
the  operation,  the  external  wounds  en- 
tirely healed,  but  he  died  suddenly. 
An  examination  of  the  skull  and  brain 
after  death  showed  that  the  tumor  of 
the  hypophysis  was  an  epithelioma  with 
several  prolongations  into  other  parts 
of  the  skull  and  around  the  cavernous 
sinus.  It  was  entirely  unencapsulated, 
and  could  not  have  been  removed  by 
the  route  taken  or  any  other.  Lecene 
(La  Presse  medicale,  Oct.  23,  1909). 

The  writer  performed  the  following 
operation  on  the  cadaver :  An  incision 
is  made  from  the  frenulum  of  the 
upper  lip  to  the  last  tooth  through  the 
mucous  membrane  and  periosteum  down 
upon  the  facial  wall  of  the  antrum  of 
Highmore,  which  is  laid  bare  and  then 
removed.     The    mucous    membrane    of 


332 


ACROMEGALY    (LAUNOIS  AND   CESBRON). 


the  antrum  is  then  removed,  a  portion 
of  the  medial  wall  chiseled  away,  the 
sphenoidal  sinus  entered  anil  removed 
as  thoroughly  as  possible  with  chisel, 
forceps,  and  sharp  spoon.  The  poste- 
rior part  of  the  septum  is  then  removed 
with  a  few  blows  of  the  chisel,  the 
sphenoidal  rostrum  cut  through,  and 
the  septum  between  the  cavities  re- 
moved. This  leaves  the  bone  beneath 
the  hypophysis  exposed  and  ready  to  be 
cut  through  with  the  chisel.  Fein 
(Wiener  klin.  Woch.,  July  14,  1910). 

McArthur  has  operated  by  a  lateral 
route,  advancing  to  the  middle  along  the 
roof  of  the  orbit  and  in  the  one  in- 
stance was  able  to  remove  about  two- 
thirds  of  the  growth.  The  author  be- 
lieves that  the  nasal  route  is  the  best, 
despite  the  resulting  deformity.  He 
reports  on  6  cases  of  tumor  of  the 
pituitary.  Case  I  was  diagnosed  from 
the  menstrual  history,  double  temporal 
hemianopsia,  optic  atrophy,  and  the 
X-ray  picture,  but  no  operation  was 
performed.  Case  II,  a  boy  of  14,  had 
no  evidence  of  acromegaly.  Headache 
came  on  at  intervals  since  the  third 
year,  with  vomiting,  frequently  ter- 
minating in  nosebleed,  with  apparent 
relief.  Double  optic  atrophy  with 
hemianopsia  showed  a  pituitary  cyst 
with  calcareous  plates.  This  case  was 
operated  by  Horsley,  and  a  pituitary 
cyst  containing  chocolate-like  fluid  was 
evacuated.  The  convalescence  was  sat- 
isfactory, but  the  boy  died  eighteen 
months  after  the  operation.  Case  III, 
a  woman  of  25  years,  ceased  to  men- 
struate at  22,  had  headaches,  bilateral 
nasal  atrophy,  and  diminution  of  the 
eye-grounds.  An  X-ray  showed  a  much 
enlarged  sella  turcica.  At  operation, 
going  over  the  orbital  plates,  a  cyst  of 
the  pituitary  was  reached  and  evac- 
uated, but  the  frontal  lobe  was  lacerated 
in  the  procedure,  and  the  patient  died 
in  eighteen  hours.  Case  IV,  a  man  of 
36  years,  had  for  five  months  noticed 
the  eyesight  of  left  eye  failing,  and  he 
had  intense  left-sided  headaches,  which 
became  less  in  the  last  two  months. 
The  field  of  vision  showed  a  sharply 
defined,  right-sided,  temporal  hemian- 
opsia.    The  patient  had  been  impotent 


for  a  year.  An  X-ray  showed  an  en- 
larged sella  turcica.  He  was  operated 
by  von  Eiselsberg  by  the  nasal  route, 
and  recovered.  The  tumor  was  a 
malignant  epithelioma.  Case  V,  a  boy 
aged  14,  for  one  year  had  noticed  his 
vision  getting  bad,  and  later  there  were 
temporal  headaches;  later  hemianopsia 
was  found  and  atrophy  of  the  disk. 
The  X-ray  showed  an  enlarged  sella. 
Though  operation  was  refused,  the  boy 
lived  over  four  years  after  the  symp- 
toms of  tumor  were  felt.  Case  VI,  a 
man  of  33,  had  for  six  years  noticed 
failing  vision  in  one  eye,  and  later  of 
the  other,  the  outer  half  of  the  field 
going  first ;  marked  atrophy  of  the  disk 
on  one  side.  The  X-ray  showed  a 
large  sella  turcica.  No  operation  was 
performed,  because  the  patient  was  in 
such  excellent  good  health,  with  no 
other  symptoms  than  those  of  the  eyes. 
Church  (Jour.  Amer.  Med.  Assoc,  July 
10,  1909;  Interstate  Med.  Jour.,  Feb., 
1910). 

The  author  is  inclined  to  think  that 
cases  of  the  Marie  type,  with  hyper- 
plasia or  the  adenomatous  condition, 
represent  hyperpituitarism,  and  that 
cases  of  the  Frohlich  group  represent 
hypopituitarism  in  consequence  of  in- 
vasion of  compression  of  the  gland  by 
a  tumor  or  cyst. 

The  case  reported  was  one  of  acro- 
megaly in  a  man  of  38.  Constant  head- 
ache and  photophobia  were  prominent 
symptoms,  and  these  were  practically 
cured  by  partial  hypophysectomy — 
which  was  followed,  also,  by  marked 
reduction  in  the  thickening  of  the 
fingers,  tongue,  and  jaw. 

For  this  operation  temporary  tra- 
cheotomy was  first  performed.  In 
Rose's  position  an  omega  flap  was  made 
over  the  frontal  sinuses,  continued 
down  on  each  side  of  the  nose  to  the 
base  of  the  nasal  bones.  An  osteoplas- 
tic flap  was  then  turned  down.  An 
opening  was  made  in  each  frontal  sinus, 
and  these  were  joined  by  a  Gigli  saw; 
with  forceps  the  lateral  incisions  of  the 
proposed  frontonasal  flap  were  carried 
down  through  the  nasal  bones;  the 
median  septa  were  divided  with  chisel. 
The    ethmoidal    cells    were    rongeured 


ACTINOMYCOSIS    (LAPLACE). 


333 


away  to  provide  a  channel  2  cm.  wide, 
below  the  ethmoidal  roof,  to  the  poste- 
rior part  of  the  nasal  fossa.  The 
sphenoidal  cells  were  then  broken  into, 
the  projecting  sella  turcica  exposed  and 
chiseled  away.  The  dura  enveloping 
the  pituitary  glr.nd  was  thus  exposed. 
It  was  incised,  and  about  one-half  of 
the  exposed  portion  of  the  gland  was 
removed,  piecemeal,  by  curette.  Two 
cigarette  drains  were  introduced  into 
the  sphenoidal  cells,  one  emerging  from 
each  nostril.  The  frontonasal  flap  was 
then  sutured  in  place.     Primary  union. 

In  addition  to  tracheotomy,  plug- 
ging of  the  posterior  nares  and  swab- 
bing the  nares  with  adrenalin  preceded 
the  operation.  Urotropin  administered 
for  twenty-four  hours  before  operation. 
Anesthesia  by  warmed  ether  vapor. 

In  dogs  the  hypophysis  is  easily  ex- 
posed by  the  lateral  cranial  route,  bi- 
lateral craniectomy  being  performed  to 
allow  dislocation  of  the  brain  (Paul- 
esco).  In  man  the  exposure  by  this 
route  is  hazardous,  if  not  impossible, 
and  Horsley's  approach  (temporal  in- 
tracranial) seems  to  be  eligible  only  for 
a  growth  lying  well  above  the  sella  tur- 
cica. The  transsphenoidal  operations 
are  those  of  choice  for  growths  within 
the  sella  turcica,  as  first  advocated  by 
Schlofifer,  and  of  these  the  writer  re- 
gards as  best  a  direct  median  approach 
through  the  nose  (extracranial).  Har- 
vey Cushing  (Annals  of  Surg.,  Dec, 
1909;  Amer.  Jour,  of  Surg.,  March, 
1910). 

From  this  brief  discussion  of  the  sur- 
gical aspect  of  acromegaly  we  may  con- 
clude that  hypophysectomy  is  practi- 
cable in  the  human  subject  by  the  nasal 
route,  and  that  it  represents  a  relatively 
safe  operation.  Surgical  intervention 
has  yielded  results  which  could  not  have 
been  hoped  for  from  any  mode  of  treat- 
ment previously  employed. 

•   P.  E.  Launois 

AND 

M.  H.  Cesbron, 
Paris. 


ACTINOMYCOSIS .—  D  E  FI NI- 
TION.  —  A  parasitic,  infectious,  and 
inoculable  disease  due  to  the  develop- 
ment of  the  actinomyces,  or  ray  fungus. 
First  described  in  1877  in  cattle  by  Bol- 
linger and  in  man  by  James  Israel ;  it 
can  no  longer  be  considered  a  rare  dis- 
ease. From  its  frequent  development 
in  the  lungs  it  has  often  been  confused 
with  tuberculosis. 

SYMPTOMS.— The  symptoms  vary 
according  to  the  locality  of  the  disease. 
The  affection  is  chronic  and  exception- 
ally rapid.  The  granulation  tissue  is 
abundant  and  the  mass  resembles  a 
tumor.  Previous  to  suppuration  it  is 
quite  firm,  and,  if  progressing  rapidly, 
is  surrounded  by  diffuse  edema.  Pain 
and  tenderness  hardly  ever  exist.  When 
suppuration  occurs  the  mass  increases 
rapidly  in  size. 

Actinomycosis  may  develop  in  almost 
any  part  of  the  body,  but  Poncet  and 
Berard  showed,  after  an  investigation 
of  500  reported  cases,  that  the  sites  of 
predilection  were  relatively  as  follows : 
Head  and  neck,  55  per  cent. ;  thorax 
and  lungs,  20  per  cent. ;  abdomen,  20 
per  cent. ;  other  parts,  5  per  cent.  In 
France  the  face  and  neck  were  affected 
in  85  per  cent,  of  the  66  cases  reported. 

1.  Cutaneous  Surface.  —  Usually,  a 
lesion  of  the  skin  is  secondary  to  the 
evolution  of  an  underlying  actinomy- 
cotic tumor,  which,  by  its  growth,  bursts 
through  the  skin.  A  sanguineous  or 
purulent  liquid,  containing  the  charac- 
teristic grains,  issues  from  the  ulcera- 
tions so  formed.  The  grains  are  small, 
opaque,  yellowish-white,  or  yellowish 
masses  about  as  large  as  a  pinhead, 
which  are  composed  of  smaller  grains, 
measuring  about  %o  t^^^'^-  These  smaller 
grains  are  formed  by  a  central  mass,  of 
interwoven  or  straight  fibers,  whence  ex- 
tend toward  the  periphery    spoke-like 


334 


ACTINOMYCOSIS    (LAPLACE). 


prolongations,  with  club-like  termina- 
tions. Rarely  the  affection  may  develop 
primarily  on  the  fingers,  hand,  nose,  or 
face.  It  forms  a  small,  round,  ligneous 
mass,  which  may  soften  in  a  few  weeks, 
burst  through  the  skin,  and  give  a  gran- 
ulous  and  varied  pus,  containing  actino- 
mycotic granulations.  The  border  of  the 
granulation  is  uneven,  violet-hued,  and 
undermined.  Around  the  original  mass 
there  arise  secondary  masses ;  so  that 
the  entire  lesion  forms  a  violet-red,  in- 
durated patch,  deeply  adherent,  and 
somewhat  resembling  scrofuloderma. 

In  cutaneous  actinomycosis  the  lym- 
phatic ganglia  are  usually  not  enlarged. 
Pain  is,  in  some  cases,  intense ;  in  other 
cases  it  is  awakened  only  by  pressure. 
The  pathognomonic  spots,  which  are 
more  or  less  deep  in  color,  according  as 
the  general  color  of  the  lesion  is  more 
or  less  pronounced.  If  the  general  color 
is  pale, the  spots  are  bluish  red  or  violet ; 
if  the  tint  of  the  mass  is  deeper,  the 
spots  present  a  blackish  or  slate  color. 
These  spots  vary  in  size  from  that  of  a 
pea  to  that  of  a  pin's  head.  They  ap- 
pear to  correspond  to  the  points  at 
which  the  wall  of  the  abscess  is  thinnest, 
and  it  is  here  alone  that  fistulse  form. 

In  some  instances,  as  in  the  case  re- 
ported by  Pringle  and  illustrated  in  the 
annexed  colored  plate,  the  lesions  may 
assume  the  appearance  of  large  sarco- 
matous-looking  growths,  ulcerating  at 
various  points,  situated  upon  hard, 
brawny,  and  deeply  undermined  skin 
and  from  the  ulcerative  points  of  which 
pus  exudes,  mixed  with  characteristic 
yellow  granules,  actinomycosis. 

2.  Alimentary  Canal. — Teeth. — The 
fungus  has  been  found  in  carious  teeth 
(Israel),  often  side  by  side  with  lepto- 
thrix  (Senn),  or  almost  pure  culture 
with  no  manifestation  of  disease  except 
chronic  periodontitis  (Partsch).     Cari- 


ous teeth  have  increasingly  been  shown 
to  be  the  origin  of  the  affection. 

Tongxie  and  Tonsils. — In  man  three 
cases  of  this  affection  have  been  found 
on  the  tongue,  one  of  which  was  of  pri- 
mary development ;  the  other  two  are 
believed  to  have  found  origin  in  a  ca- 
rious tooth.  The  tonsils  may  also  be 
affected  and  be  the  seat  of  white  projec- 
tions resembling  masses  of  moss,  which 
seemed  to  grow  in  the  crypts.  The 
pharyngeal  wall  also  shows  these  white 
masses,  as  a  rule. 

Lingual  actinomycosis  in  cattle  ap- 
pears as  a  nodular  tumor,  with  prolon- 
gations into  the  parenchyma,  of  ligneous 
hardness. 

Jaws. — The  lower  jaw  is  the,  most 
frequently  affected.  At  first  the  disease 
resembles  periosteal  sarcoma,  until  the 
loose  tissues  of  the  neck  are  reached, 
when  it  often  rapidly  extends  downward 
along  the  subcutaneous  connective  tis- 
sues and  intermuscular  septa.  Accord- 
ing to  Poncet,  an  early  sign  of  actino- 
mycosis in  this  location,  in  some  cases, 
is  a  marked  difficulty  in  opening  the 
mouth,  long  before  the  presence  of  the 
disease  can  be  determined  microscopic- 
ally. 

Eight  cases  tending  to  show  that  a 
proportion  of  the  cases  ranking  as 
alveolar  abscesses  may  be  due  to  the 
specific  organism  of  actinomycosis. 
Few  cases  enter  hospital  with  ad- 
vanced actinomycosis  of  the  jaw,  and 
many  recover  after  simple  incision 
and  after  rupture.  Certain  cases  of 
generalized  disease  in  the  lungs,  in- 
testinal tract,  liver,  etc.,  occur  in 
which  the  organism  gained  entrance 
through  the  food,  or  was  swallowed, 
and  therefore  the  surgeon  should  aim 
at  making  external  drainage.  C.  A. 
Porter  (Boston  Med.  and  Surg.  Jour., 
Sept.  13,  1900). 

The  upper  jaw  is  rarely  primarily 
affected.    It  then  tends  to  attack  rapidly 


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ACTINOMYCOSIS    (LAPLACE). 


335 


the  adjacent  parts,  and  even  the  base  of 
the  skull  and  brain. 

Autopsy  indicating  that  actinomy- 
cosis of  the  middle  ear  may  arise 
from  blood-infection  from  a  primary 
focus  elsewhere  in  the  body,  or  from 
a  neighboring  actinomycotic  process 
in  the  mouth,  pharynx,  tonsil,  or  from 
carious  teeth;  that  the  fungus  may 
enter  the  middle  ear  through  the 
Eustachian  tube  or  through  the  ex- 
ternal auditory  canal.  J.  C.  Beek 
.  (Prager  med.  Woch.,  Mar.  29,  1900). 

In  three  cases  the  predominant 
sign  was  a  sharply  defined  local  mov- 
able mass,  which  is  always  strongly 
indicative  of  the  disease.  Hofmeister 
(Beit.  z.  klin.  Chir.,  B.  26,  H.  2,  1900). 

In  the  case  of  a  butcher  the  first 
signs  were  in  the  floor  of  the  mouth, 
in  the  form  of  a  pseudoranula;  after- 
ward swelling  of  the  cheek  showed 
characteristic  yellowish  discharge  and 
granules.  Lenoir  and  Claisse  (Jour, 
des  Praticiens,  July  14,  1900). 

3.  Intestinal  Canal. — The  disease  be- 
gins with  a  sharp,  lancinating  pain  in 
the  abdomen  and  follows  the  course  of 
chronic  peritonitis.  Swellings  forming 
abscesses  are  found  on  the  anterior  ab- 
dominal wall,  which  sometimes  commu- 
nicate with  the  intestine.  It  may  also 
start  from  the  vermiform  appendix. 
There  have  also  been  cases  of  primary 
actinomycosis  of  the  colon  with  meta- 
static deposits  in  the  liver. 

Actinomycosis  of  the  vermiform  ap- 
pendix was  first  recognized  by  Barth 
in  1890,  and  was  first  recognized  in 
England  in  1892  by  Ransom.  It  has 
become  evident,  however,  that  a  num- 
ber of  cases  really  originate  in  the 
cecum,  and  an  identical  clinical  pic- 
ture may  result  after  perforation. 
Hence  a  preferable  title  would  be 
"actinomycotic  perit3rphlitis."  Three 
cases  observed  by  the  writer  in  one 
year,  and  he  describes  three  more 
from  the  annals  of  the  Bristol  Royal 
Infirmary.  Grill  mentions  11  cases 
of    actinomycotic    perityphlitis     as     re- 


corded up  to  1895.  It  is  proI)able 
that  the  total  number  up  to  1904  is 
about  150,  of  which  27  are  English. 
The  proportion  as  to  the  sexes  is 
about  5  males  to  2  females.  It  is 
more  frequently  seen  between  20  and 
30  years  of  age.  A  large  number  of 
sufferers  are  connected  in  some  way 
with  farm  life,  or  deal  with  corn. 
Short  (Lancet,  Sept.  14,  1907). 

4.  Genitourinary  Tract. — The  uterus 
may  also  become  invaded  by  the  disease, 
the  first  manifestation  being  the  dis- 
charge of  a  turbid,  fetid  fluid  contain- 
ing the  characteristic  shreds  and  masses. 

Case  of  a  peasant  woman  in  which 
the  labium  majus  was  swollen  and 
covered  with  orifices  of  fistute  dis- 
charging pus.  The  tracts  were  slit 
up  freely  and  scraped;  the  actinomy- 
ces  was  detected  by  aid  of  the  micro- 
scope. Three-quarters  of  a  year 
later  no  signs  of  recurrence  could  be 
detected.  Only  two  similar  cases 
have  been  recorded,  one  by  the  writer 
himself,  and  one  b}'-  Lieblein,  of 
Prague.  '  Bongartz  (Monats.  f.  Geb. 
u.  Gyn.,  Nov.,  1902). 

Up  to  the  present  only  one  case 
(von  Israel)  of  the  primary  renal  ac- 
tinomycosis has  been  published.  The 
writer  reports  a  second  case,  which  oc- 
curred in  a  hoy,  aged  \?>/^  years,  who, 
like  von  Israel's  patient,  was  oper- 
ated on  Avith  successful  result.  Ku- 
nith  (Deut.  Zeit.  f.  Chir,  Bd.  xcii,  S. 
181,   1908). 

The  gross  macroscopic  and  micro- 
scopic picture  resembles  that  of  tu- 
berculosis in  many  cases.  Bollinger's 
desideratum  for  the  diagnosis  of 
actinomycosis,  namely,  that  corpora 
flava  must  be  present,  is  untenable 
at  the  present  time.  Repeated  bac- 
teriological examinations,  and  some- 
times long  and  tedious  ones,  of  the 
same  specimens  must  be  made  to 
insure  a  correct  interpretation  of  sus- 
picious pathological  material.  Inocu- 
lation with  pure  cultures  into  the  ani- 
mal is  not  attended  with  success. 
Only  the  injection  of  pus  with  actino- 
mycosis,   or   the    ingestion    of    material 


336 


ACTINOMYCOSIS    (LAPLACE). 


upon  which  actinomycosis  is  grown, 
will  prove  successful  in  the  production 
of  actinomycosis  in  the  animal.  Actino- 
mycosis does  not  travel  by  the  lym- 
phatics, and  probably  not  by  the  blood 
route.  The  prognosis  is  favorable  in 
circumscribed  cases,  which  is  most 
likely  the  condition  in  which  we  find 
the  uterine  appendages. 

The  treatment  consists  in  radical 
extirpation  and  free  drainage,  the  appli- 
cation of  tribromphenolbismuth,  or 
irrigation  of  the  fistula  with  copper 
sulphate.  The  internal  administration 
of  large  doses  of  iodide  of  potash  up 
to  75  grains  a  day,  which  exerts  a  posi- 
tive healing  effect.  Carl  Wagner 
(Surg.,  Gynec.  and  Obstet,  Feb.,  1910). 

5.  Respiratory  Tract. — Inbronchitic 
actinomycosis  the  affection  is  less  severe 
in  winter  than  in  summer,  which  is  the 
contrary  of  what  is  observed  in  ordi- 
nary bronchitis.  It  can  be  classified  in 
three  groups:  (1)  lesions  of  chronic 
bronchitis;  (2)  miliary  actinomycosis, 
and  (3)  cases  with  bronchopneumonia 
and  abscesses.  The  lower  lobe  is  at- 
tacked more  frequently  than  the  upper ; 
the  opposite  is  the  case  in  tuberculosis. 

Review  of  14  recorded  cases  of  ac- 
tinomycosis of  the  lung.  The  only  2 
which  recovered  were  those  in  which 
radical  operations,  with  resection  of 
four  or  five  ribs,  and  cauterization 
of  the  diseased  cavity  in  the  lung 
were  carried  out.  All  those  that  were 
simply  incised  and  drained  ended 
fatally.  The  infection  of  the  lung 
may  be  secondary  to  either  cervico- 
facial or  pharyngoesophageal  actino- 
mycosis, or  it  may  be  primary,  either 
through  the  bronchi  or  from  an  ex- 
ternal wound.  There  are  three  forms 
clinically:  (1)  the  pulmonary,  with 
insidious  onset,  going  on  to  induration 
of  a  large  area  of  lung,  generally  in 
the  subclavicular  or  posterolateral  re- 
gions, the  apices  being  usually  free; 
(2)  the  bronchial,  with  a  diffuse  catarrh 
and  fetid  mucopurulent  expectoration, 
containing  the  fungus;  (3)  the  pleural, 
with     effusion;     the     coexistence     of 


pleural  eft'usion  with  retraction  of  some 
part  of  the  thoracic  parietes — due  to 
fibrous  changes  in  the  lung — is  pa- 
thognomonic. Another  pathognomonic 
symptom  is  the  presence  of  a  swelling 
in  the  wall  of  the  thorax  where  it  has 
been  invaded  by  the  fungus,  along  with 
shrinking  of  the  lung,  causing  retrac- 
tion of  the  thoracic  walls ;  later  on  this 
softens  and  becomes  subfluctuating 
without  the  formation  of  large  ab- 
scesses. Puncture  obtains  a  fluid  con- 
taining fragments  of  fungus.  Death 
may  occur  after  months  or  years,  ac- 
cording to  the  varying  invasion  of 
other  organs  by  the  disease ;  in  one 
case  of  rapid  diffusion  of  the  fungus 
death  occurred  in  twenty- four  days. 
Parascandolo  (Brit.  Med.  Jour.,  from 
Clinica  Mod.,  Nov.  7,  1900). 

Mammary  actinomycosis  may  occur 
in  two  ways:  primary  and  secondary. 
In  the  former  infection  occurs  either 
from  propagation  of  the  actinomy- 
cotic grains  in  the  milk-ducts  or  from 
their  penetration  into  the  tissues 
through  a  continuity  of  the  skin. 
Four  cases  of  the  primary  form  wit- 
nessed. The  secondary  form  spreads 
to  the  mammae  from  the  lung  (most 
frequently)  or  some  other  organ. 
The  disease  is  not  easy  of  diagnosis, 
and  is  liable  to  be  confused  with  tu- 
bercle, cancer,  interstitial  inflamma- 
tion, or  syphilitic  disease,  and  re- 
peated microscopical  examination  of 
discharges  or  pieces  of  tissue  should 
be  made.  The  prognosis  in  the  pri- 
mary form  is  good,  but  in  the  second- 
ary form  unfavorable.  Mileff  (Gaz. 
d.  Hop.,  Jan.  1,  1901). 

The  diagnosis  of  "primary  pul- 
monary actinomycosis,"  even  in  the 
absence  of  all  abdominal  symptoms, 
must  remain  doubtful  without  a  post- 
mortem examination.  In  abdominal, 
as  well  as  in  pulmonary,  actinomycosis 
the  patient  should  be  closely  ques- 
tioned regarding  any  previous  more 
or  less  indistinct  symptoms  of  ap- 
pendicitis and  sores  at  the  anus. 
Fecal  concrements  found  in  the  ap- 
pendix in  cases  of  actinomycosis 
should  be  microscopically  examined. 
In  actinomycosis  following  typhoid- 


ACTINOMYCOSIS    (LAPLACE). 


337 


like  symptoms,  a  Widal  test  should 
be  made.  At  the  post-mortem  special 
attention  must  be  paid  to  intestinal 
scars,  which  may  easily  avoid  de- 
tection. Experiments  and  clinical 
observation  indicate  that  the  fungus 
cannot  enter '  the  human  or  animal 
body  without  a  wounded  surface. 
Must  the  wounded  body  also  be  the 
carrier  of  the  infectious  material,  or 
can  infection  take  place  secondarily 
through  a  granulating  accidental 
wound  or  the  chronic  ulcers  de- 
scribed? Human  actinomycosis  of 
the  skin,  or  actinomycosis  of  the  jaw 
in  pasturing  cattle,  may  offer  a  suit- 
able object  for  investigation  in  re- 
gard to  the  latter  point.  Fritz  Maas 
(Annals   of   Surg.,  Aug.,   1903). 

Case  of  intralaryngeal  actinomyco- 
sis. The  patient,  aged  19,  first  noticed 
a  slight  hoarseness,  which  gradually 
increased  until  he  could  speak  only 
in  a  whisper;  it  was  for  this  symptom 
alone  that  he  sought  relief.  There 
was  at  times  a  slight  "stinging"  in 
the  throat,  which  had  never  been 
more  than  disagreeable.  There  had 
been  a  slight  cough  and  some  dysp- 
nea on  exertion.  In  the  region  of 
both  true  cords  and  completely  cov- 
ering and  concealing  them  were  ir- 
regular masses  of  dirty-white  tissue, 
more  than  half  occluding  the  chink 
of  the  glottis.  The  same  sort  of  tis- 
sue lined  the  trachea  as  far  down  as 
the  writer  could  see,  which  was  but 
a  short  distance,  by  reason  of  the 
encroachment  on  its  lumen  by  this 
adventitious  material.  The  man  was 
given  vigorous  antisyphilitic  treat- 
ment for  a  month,  without  improve- 
ment. After  he  had  been  under  ob- 
servation for  about  three  months, 
several  portions  of  the  laryngeal  mass 
were  removed  and  examined  micro- 
scopically. The  diagnosis  of  actino- 
mycosis was  then  made.  The  patient 
was  put  on  increasing  doses  of  potas- 
sium iodide  without  apparent  improve- 
ment, although  there  soon  was  no 
evidence  of  actinomj'-cosis  in  the 
sputum.  There  were  present  occa- 
sional tubercle  bacilli,  streptococci, 
and   groups    of    staphylococci.      This 


condition  gradually  became  worse. 
Physical  signs  of  consolidation  were 
discoverable  in  the  right  upper  lobe. 
There  were  some  cough,  emaciation, 
irregularity  of  temperature,  anorexia, 
and  digestive  derangement.  At  the 
last  examination  there  was  an  area 
in  the  vault  of  the  pharynx  which  pre- 
sented an  appearance  identical  with  that 
in  the  larynx — previously  there  had 
been  absolutely  no  lesion  discoverable 
elsewhere  than  within  the  larynx.  The 
physical  signs  then  present  were  the 
classical  ones  of  early  pulmonary  tuber- 
culosis. Arrowsmith  (Laryngoscope, 
Oct.,   1910). 

Actinomycosis  of  the  lungs  is  found 
in  20  to  30  per  cent,  of  all  cases  of 
actinomycosis.  It  probably  originates 
in  the  mouth,  and  usually  takes 
the  form  of  bronchitis  or  broncho- 
pneumonia. The  diagnosis  is  made 
by  finding  the  "sulphur  granules"  in 
the  sputum,  and  the  streptothrix  un- 
der the  microscope.  J.  O.  Alksne 
(Deut.  Aerzte  Zeit.,  Mar.  15,  1910). 

6.  Brain. — Here,  tumor-like  symp- 
toms exist  during  life,  with  headache, 
paralysis  of  the  abducens,  congestion  of 
the  optic  papilla,  and  attacks  of  uncon- 
sciousness. In  a  case  reported  by  Ran- 
son  the  autopsy  indicated  the  probable 
mode  of  infection  of  the  orbit  and  brain. 
A  sinus  was  found  leading  from  the 
orbit  to  the  gum  of  the  upper  jaw;  the 
ray  fungus  had  probably  lodged  in  or 
near  a  tooth,  as  it  has  so  often  been 
found  to  do.  The  fungus  was  probably 
carried  into  the  system  on  an  ear  of 
corn  chewed  at  harvesttime.  Having 
reached  the  orbit,  it  crept  along  its  outer 
wall  and  in  the  wall  of  the  right  cavern- 
ous sinus  to  the  base  of  the  brain,  ulti- 
mately setting  up  meningitis  and  small 
abscesses,  and  burrowing  through  the 
pituitary  body  and  sella  turcica  to  the 
cavernous  sinus  of  the  left  side. 

The  orbit  is  very  seldom  the  seat 
of  actinomycosis.  A  case  is  reported 
from    von    Brun's    clinic,    and   9    cases 


338 


ACTINOMYCOSIS    (LAPLACE). 


are  cited  in  detail  from  the  literature. 
The  author's  case  was  the  first  to  be 
operated  upon  by  temporary  resec- 
tion of  the  upper  part  of  the  cheek- 
bone, a  procedure  which  is  consid- 
ered superior  to  Kronlein's  resection 
of  the  lateral  portion  of  the  orbit. 
The  chief  symptoms  were  exophthal- 
mos and  failure  of  vision  in  the  af- 
fected eye.  There  was  also  lack  of 
mobility  of  the  eyeball.  These  symp- 
toms are,  however,  not  pathognomo- 
nic of  actinomycosis,  it  being  essential 
to  an  exact  diagnosis  that  the  ray 
fungus  be  found  in  the  pus.  As  soon 
as  a  diagnosis  is  made,  or  there  is  a 
well-grounded  suspicion  of  this  dis- 
ease, steps  should  be  taken  to  radi- 
cally remove  the  focus  of  infection. 
Miiller  (Beitriige  z.  klin.  Chir.,  Bd. 
68,  H.   1,  1910). 

DIAGNOSIS. — When  the  process  is 
very  rapid,  actinomycosis  may  stimulate 
acute  phlegmonous  inflammation  and  os- 
teomyelitis, or,  when  widespread,  syph- 
ilis. 

A  study  of  all  cases  reported  showed 
that  the  clinical  characteristics  vary 
greatly  with  the  region  of  the  body 
involved.  In  the  cervicofacial  and 
cutaneous,  as  well  as  in  many  of  the 
thoracic  and  abdominal,  cases  the 
first  symptoms  noticed  were  pain  and 
swelling,  though  the  pain  was  not 
often  severe  and  may  be  absent  en- 
tirely. Fever  above  101°  F.  is  rare, 
and  examination  of  the  blood  shows 
a  leucocytosis,  averaging  17,000.  In- 
jections of  tuberculin  failed  to  give 
a  febrile  reaction.  Cervicofacial  cases 
are  often  mistaken  at  first  for  tooth- 
ache; in  thoracic  forms  the  first  symp- 
toms are  those  of  bronchitis  or  pleurisy, 
and  abdominal  cases  often  resemble 
appendicitis.  The  diagnosis  should 
never  be  positive  without  finding  of  the 
organisms  which  occur  in  the  sulphur 
granules  of  the  abscess  contents.  Al- 
though the  progress  of  the  disease  is 
sluggish,  extension  is  prone  to  follow 
by  direct  involvement  of  the  contiguous 
tissues  or  by  metastases.  W.  G.  Erving 
(Bull.  Johns  Hopkins  Hosp.,  Nov., 
1902). 


Sarcoma. — This  form  of  neoplasm 
does  not  suppurate  or  break  down  so 
early. 

In  the  jaws  it  is  to  be  differentiated 
from  dental  affections :  epulis. 

Tuberculosis. — In  this  disease  the 
lymphatic  glands  are  infected,  and  the 
apices  are  usually  the  first  involved. 

Carcinoma. — The  skin  or  mucous 
membrane  involved  is  in  close  connec- 
tion with  the  tumor;  in  actinomycosis 
the  skin  will  be  found  broken  on  micro- 
scopical examination. 

Case  of  a  farmer  suffering  from 
actinomycosis  of  the  jaw.  After  the 
disease  existed  for  upward  of  a  year, 
a  surgeon  diagnosed  it  as  cancer,  and 
advised  removal  of  the  right  half  of 
the  lower  maxilla.  Three  months 
later  this  patient  was  exposed  to  the 
X-ray  treatment  for  three  months, 
twenty-five  applications  of  the  light 
being  made  in  that  time.  The  treat- 
ment was  perfectly  futile.  After  three 
months'  rest  the  patient  consulted  a 
second  X-ray  specialist,  who  gave 
twenty  applications  in  nine  weeks 
with  negative  results.  Iodine  treat- 
ment, begun  two  years  from  the  be- 
ginning of  his  trouble,  was,  however, 
followed  by  a  marked  improvement. 
Heidingsfeld  (Cincinnati  Lancet- 
Clinic,  Mar.  28,  1903). 

Many  actinomycotic  tumors  have 
been  removed  surgically  under  the 
impression  that  they  were  due  to  can- 
cer, and  a  cure  of  the  latter  hailed  in 
consequence  of  their  non-recurrence. 
Mercury  and  the  iodides  will  cure  ac- 
tinomycosis, which  is  thus  often  mis- 
taken for  syphilis  to  the  normal  det- 
riment of  the  patient;  the  iodide 
treatment,  however,  is  counseled  in 
all  doubtful  cases.  Poncet  and  Ber- 
ard  (Lyon  Med.,  Mar.  27,  1904). 

Syphilis. — A  gumma  will,  in  two  or 

three    weeks,  be   sensibly    affected    by 

large  doses  of  potassium  iodide,  which 

does  not  act  so  rapidly  in  actinomycosis. 

The  undoubted  influence  exercised 

by  iodide  of  potassium  countenances 


ACTINOMYCOSIS    (LAPLACE). 


339 


the  suspicion  that  many  patients  sup- 
posed to  be  syphilitic  have  really 
been  actinomycotic.  ■  Poncet  (Glas- 
gow Med.  Jour.,  April,  1S9S). 

Lupus, — The  diagnosis  depends,  in 
thhs  condition,  upon  microscopical  ex- 
amination. 

Ten  cases  which  simulated  actino- 
mycosis, but  in  which  the  causal 
agent  was  either  the  Cladothrix  lique- 
faciens  or  the  bacillus  described  by 
Sawtschenko.  Radical  removal  of  the 
focus  is  the  only  treatment.  G.  Kle- 
seritzky  and  L.  Bornhaupt  (Archiv 
f.  klin.  Chir.,  Bd.  Ixxvi,  Nu.  4,  1905). 

Case  of  actinomycosis  of  the  big 
toe,  in  which  there  was  marked  re- 
semblance of  the  pathological  and 
microscopical  picture  to  Madura  foot. 
The  patient  had  had  inflammation  of 
the  big  toe,  with  suppuration  of  the 
matrix  of  the  nail,  followed  some 
months  after  its  complete  subsidence 
by  another  thickening  of  the  toe,  but 
without  any  pain  or  other  disturb- 
ance. Two  years  after  the  shedding 
of  the  nail  the  toe  rapidly  increased 
to  the  triple  circumference  of  the  op- 
posite toe,  A^esicles  appearing  on  the 
skin  and  undergoing-  suppuration. 
The  toe  was  amputated,  and  the  ex- 
amination showed  the  presence  of 
actinomycosis.  Kulbs  (Wiener  klin. 
Woch.,    Nu.   2,    1907). 

The  writer  was  able  to  differen- 
tiate actinomycosis  by  the  seroreac- 
tion  in  8  cases,  the  only  negative 
reaction  being  in  a  case  in  which  the 
cure  had  been  complete  for  over  four 
years.  The  specific  reaction  is  both 
by  agglutination  and  by  fixation  of 
complement  by  means  of  the  spores 
of  the  sporotrichum.  Actinomyces 
cultures  cannot  be  used  for  the  tests, 
but  the  generic  reaction  with  sporo- 
thrix  spores  is  constant  and  lively. 
It  is  specific  for  actinomycosis,  sporo- 
trichosis, and  thrush,  but  these  can  be 
readily  distinguished.  Widal  (Bull, 
de  I'Acad.  de  Med.,  May  10,  1910). 

ETIOLOGY. — Both  men  and  ani- 
mals are  probably  infected  from  vege- 


tables or  water  (Israel),  from  eating 
ears  of  barley,  or  rye,  when  the  fungus 
penetrates  through  the  wound  or  abra- 
sion thus  provoked,  or  in  many  cases 
through  carious  teeth.  Intestinal  acti- 
nomycosis is  due  to  taking  contaminated 
food  or  water,  when  the  fungus  be- 
comes implanted  upon  an  already  dis- 
eased tissue,  multiplies,  and  causes  ac- 
tive proliferation  of  the  submucous  tis- 
sue. It  may  be  transmitted  by  kissing, 
as  in  a  case  reported  by  Baracz.  Farm- 
ers should  be  warned  against  the  habit, 
so  common  among  them,  in  chewing 
bits  of  straw,  wheat,  oat-chass,  etc.,  the 
most  prolific  cause  of  the  disease.  Ac- 
tinomycosis is  frequently  met  with  in 
shoemakers.  This  is  due  to  their  habit 
of  placing  their  needles  in  their  mouths 
(Ullmann). 

Actinomycosis  of  the  lower  jaw  ac- 
quired by  a  toothbrush-maker  in  the 
following  manner:  Hogs'  bristles 
were  washed,  then  held  in  mouth  be- 
fore sticking  into  the  handle-holes  in 
bundles.  Guinard  (Bull,  et  Mem.  de 
la  Soc.  de  Chir.  de  Paris,  T.  26,  No.  6, 
1900). 

Total  of  72  cases  of  actinomycosis 
from  American  sources  collected.  Six 
personal  cases,  2  of  which  had  not 
been  previously  reported.  In  one,  al- 
veolar abscess  followed  chewing 
wheat-grains  with  a  carious  tooth. 
In  a  second  case  a  quantity  of  pus 
collected  in  the  right  iliac  fossa.  The 
patient  died  of  malnutrition,  having 
recurred  after  evacuation.  J.  Riihrah 
(Annals  of  Surg.,  Feb.,  1900). 

All  the  reported  cases  of  actinomy- 
cosis in  man  carefully  studied.  The 
cases  are  scattered  widely  through- 
out the  country,  though  most  are  re- 
ported from  large  medical  centers. 
Less  than  20  per  cent,  come  from  the 
Southern  States.  Males  were  affected 
about  three  times  as  often  as  females. 
The  youngest  case  reported  was  a 
child  6  years  old;  t'.e  oldest  a  man 
of  70;  most  are  in  middle  life.     Con- 


340 


ACTINOMYCOSIS    (LAPLACE). 


cerning  occupation,  there  is  a  wide 
range,  but  36  per  cent,  had  much  to 
do  with  live  stock  and  grain.  The 
chronic  character  of  the  disease  was 
well  shown  by  the  fact  that  in  62  per 
cent,  it  lasted  over  six  months.  W. 
G.  Erving  (Bull.  Johns  Hopkins 
Hosp.,  Nov.,  1902). 

Large  number  of  cases  collected  in 
which  actinomycosis  which  had  re- 
mained latent  throughout  pregnancy 
suddenly  took  on  a  very  rapid  de- 
velopment as  soon  as  this  was  ended. 
The  curative  action  of  iodine  on  the 
disease  and  the  frequent  disturbance 
of  iodine  metabolism  in  pregnancy 
and  the  puerperium  may  have  some- 
thing to  do  with  this  relation.  Theve- 
not  (Revue  de  Chir.,  No.  9,  1906). 

Primary  invasion  of  the  skin  and 
subcutaneous  tissues  by  Actinomyces 
bovis  is  of  rare  occurrence.  The 
cases  number  less  than  20.  Even 
some  of  these  may  have  been  due  to 
secondary  rather  than  primary  in- 
vasion of  the  skin.  Personal  case  of 
actinomycosis  of  the  skin  of  the  foot. 
Leser  was  the  first  to  arouse  interest 
in  this  particular  localization  by  the 
publication  of  3  cases.  Leo  Buerger 
(Amer.  Jour.   Med.  Sci.,  Nov.,  1907). 

In  the  case  reported  a  scrap  of  a 
head  of  barley  was  found  sticking  in 
the  tissue  of  the  sublingual  gland,  the 
outer  end  in  one  of  its  excretory 
ducts.  Soderlund  (Upsal  a  Lakare, 
Forhandlingar,  vol.  xiv,  Nos.  3-4, 
1909). 

Only  6  cases  for  actinomycosis  of 
the  ovary  are  on  record,  and  none 
of  these  are  primary.  Case  of  the 
latter  kind  in  a  patient  who  had  lived 
in  London  for  16  years,  but  in  1903 
and  1904  was  brought  into  contact 
with  hay,  straw,  and  corn,  the  usual 
sources  of  actinomycosis,  and  it  is 
noteworthy  that  the  symptoms  date 
from  1904.  As  there  was  no  evidence 
of  disease  in  any  adjacent  organ,  the 
streptothrix  must  have  reached  the 
ovary  by  way  of  the  blood-stream, 
the  mode  of  entry  into  the  body  be- 
ing, the  authors  suggest,  some  cryto- 
genic  focus — e.g.,  the  tonsil,  through 


which,  it  is  well  known,  micro-organ- 
isms may  pass  into  the  blood-stream 
without  producing  any  local  lesion. 
Taylor  and  Fisher  (Lancet.,  Mar.  13, 
1909). 

The  writer  has  observed  a  number 
of  cases  in  which  latent  actinomy- 
cosis was  roused  to  active  prolifera- 
tion by  some  intercurrent  trauma. 
He  has  also  found  similar  instances 
in  the  literature.  There  may  be  an 
interval  of  j^ears  between  the  trauma 
and  the  manifest  actinomycotic  proc- 
ess; in  one  case  seventeen  and  in  an- 
other ten  years  had  elapsed,  and 
intervals  of  five  and  ten  years  are  by 
no  means  uncommon.  Noesske  (Med. 
Klinik,  Mar.  27,  1910). 

PATHOLOGY.— The  actinomyco- 
ses -were  formerly  thought  to  be  mold 
fungi  (hyphomycetes),  but  Bostroem, 
in  1885,  proved  by  cultivating  them  that 
they  were  a  variety  of  cladothrix,  be- 
longing to  the  schizomycetes. 

Comprehensive  study  on  the  biol- 
ogy of  the  branching  filamentous 
micro-organisms  isolated  in  pure  cul- 
ture from  13  cases  in  man  and  2  in 
cattle  of  actinomycosis.  The  writer 
considers  the  organisms  to  be  all  of 
one  species,  essentially  an  anaerobe, 
growing  well  only  in  agar  and  bouil- 
lon and  in  the  incubator.  He  found 
that  the  filaments  took  on  the  "club" 
appearance  only  when  grown  in  im- 
mediate contact  with  animal  fluids 
or  Avithin  the  animal  bod3^  Experi- 
mental inoculation  caused  the  forma- 
tion of  tumor  masses  of  small  sizes, 
which  showed  but  little  progressive 
tendency.  The  organism  could  be  re- 
gained, but  there  was  little  evidence 
that  multiplication  had  taken  place 
within   the   animal. 

The  writer  considers  Actinomycosis 
bovis  to  be  the  proper  name  for  the 
organism.  He  does  not  accept  the 
prevalent  belief,  based  on  the  work 
of  Bostroem,  Gasperini,  and  others, 
that  the  specific  infectious  agent  of 
actinomycosis  is  to  be  found  among 
certain  branching  micro-organisms 
widely     disseminated     in     the     outer 


ACTINOMYCOSIS    (LAPLACE). 


341 


world,  which  diflfer  profoundly  from 
Aciinoiiiycosis  boz'is  in  having  spore- 
like reproductive  elements.  On  ac- 
count of  the  fact  that  the  organism 
he  describes  docs  not  grow  on  all 
culture  media,  and  practically  not  at 
all  at  room  temperature,  he  does  not 
believe  that  it  has  its  usual  habitat 
outside  of  the  bod}-.  The  organism 
is  a  normal  inhabitant  of  the  secre- 
tions of  the  buccal  cavity  and  of  the 
gastrointestinal  tract.  The  part  played 
by  foreign  bodies  is  in  the  formation 
of  a  nidus  where  the  actinomycoses  de- 
velop to  form  actinomycosis,  and  he 
does  not  think  that  straw  and  like 
foreign  bodies  so  frequently  found  in 
actinomycotic  lesions  are  the  carriers 
of  the  micro-organism. 

The  "club''  formation  about  the 
filaments  is  a  protective  function. 
The  bacteria  so  frequently  found  ac- 
companying the  disease  are  important 
in  the  spread  and  continuance  of  the 
infection,  forming  new  sinuses,  to  be 
reinfected  with  Actinomycosis  bovis 
from  the  alimentary  canal.  J.  H. 
Wright  (Jour,  of  Med.  Research,  vol.. 
xiii,  p.  349,  1905). 

The  mass  is  made  up  of  granulation 
tissue,  which,  except  for  the  presence  of 
the  ray  fungus,  would  be  mistaken  for 
a  round-celled  sarcoma.  Epithelioid  ele- 
ments and  giant  cells  are  also  seen.  In 
the  granular  mass,  or  in  the  pus  coming 
from  a  case  of  actinomycosis,  the  fun- 
gus itself  appears  under  the  form  of 
small,  yellow,  brown,  or  even  green 
masses,  about  a  pinhead  in  size,  which, 
on  microscopical  examination,  are  found 
to  be  composed  of  a  central  interwoven 
mass  of  threads,  from  which  radiate 
club-shape-ended  rays ;  in  some  speci- 
mens certain  rays  project  far  beyond 
the  others.  In  man  the  clubbed  bodies 
are  frequently  absent  (Senn).  The  his- 
tological lesions  are  alike  in  the  actino- 
mycotic nodule  and  in  the  tuberculous . 
follicle;  only  the  foreign  body  differs. 
Water  or  a  weak  solution    of    sodium 


chloride  causes  the  rays  to  swell  enor- 
mously and  lose  their  shape ;  ether  and 
chloroform  have  no  action  upon  them. 

The  yellow  grains  are  not  always 
to  be  found  in  fistulas,  etc.,  unless 
they  are  carefullj^  sought  in  scrap- 
ings, etc.  An  early  diagnosis  is  es- 
sential, since  later  the  disease  may 
be  beyond  the  resources  of  therapy. 
A.  Poncet  and  L.  Berard  (Le  Bull. 
Med.,  Mar.  28,  1900). 

Case  in  which  microscopically 
there  was  no  appearance  of  the  ray 
fungus  in  the  fresh  pus,  and  yet  mi- 
croscopical examination  showed  the 
presence  of  fungus  at  once.  The  ab- 
sence of  the  typical  grouping  of  the 
micro-organisms  is  not  sufficient  to 
exclude  the  diagnosis  of  actinomy- 
cosis, as  the  micro-organisms  tend 
to  arrange  themselves  in  different 
ways  at  different  times.  W.  Silber- 
schmidt  (Deutsche  med.  Woch.,  Nov. 
21,1901). 

At  a  certain  stage  there  are  in  every 
colony  three  elements,  viz. : — 

1.  Club-shaped  formations. 

2.  A  centrally  placed  network  of 
fungous  filaments  of  varying  shape  and 
size. 

3.  Fine  coccus-like  bodies  (spores), 
which  originate  from  the  fungous  fila- 
ments, and  grow  into  long  rods  and 
branching  twigs. 

Two  types,  the  typical  and  atypical, 
should  be  recognized,  according  to  Ber- 
estneff.  Typical  actinomycosis  is  the 
disease  in  which  occur  the  charac- 
teristic mycelial  masses,  having  club- 
shaped  radiations.  Atypical  actinomy- 
cosis includes  such  diseases  as  Nocard's 
farcin  de  bccuf,  and  infections  which 
clinically  and  anatomically  resemble  ac- 
tinomycosis, and  are  caused  by  branch- 
ing mycelial  organisms  which  corre- 
spond quite  closely  to  the  cultural  pecu- 
liarities of  the  streptothrix  actinomyces, 
but  fail  to  form  the  characteristic  grains 
in  the  tissues  and  pus. 


342 


ACTINOMYCOSIS    (LAPLACE). 


Case  of  streptothricosis,  a  disease  of 
man  or  animal  due  to  one  of  the 
various  forms  of  streptothrix.  The 
manifestations  of  the  disease  probably 
differ  in  accordance  with  the  forms  of 
causative  organism.  If  organisms  of 
thread  form  are  present  the  surgeon 
can  be  reasonably  sure  of  the  diagnosis. 
If  the  threads  are  branched  he  can  be 
certain  of  it.  The  ray  fungus  is  sel- 
dom found  in  humans,  and  is  not  in- 
variably found  in  bovine  streptothricosis. 
The  appearance  of  the  disease  varies 
with  the  stage  in  which  it  is  seen.  A 
description    of    the    surface   appearance 


■jrM&Mm^smm 


a,  Ray-fungus  or  masses,  showing  central  myce- 
lium of  actinomycosis.  6,  White  blood-corpuscles, 
showing  their  relative  size.    (Poneet  and  Bc'rard.) 

of  an  early  stage  would  by  no  means 
fit  a  well-developed  or  an  advanced 
case.  The  appearance  is  greatly  changed 
by  mixed  infection  with  pyogenic  bac- 
teria. A  severe  secondary  pyogenic 
infection  may  obliterate  all  appearances 
suggestive  of  streptothricosis,  and  in 
such  a  case  it  may  be  impossible  to 
demonstrate  the  streptothrix.  Certain 
persistent  abscesses,  particularly  ab- 
scesses connected  with  the  alimentary 
tract,  are  due  to  streptothrix  infection 
and  secondary  infection  with  pyogenic 
bacteria.  J.  Chalmers  Da  Costa  (An- 
nals of  Surg.,  July,  1911). 

Staining, — The  following  stains  have 
been  used : — 

Wedl's  orseille  (Weigert). 


Eosin  (Marchand). 

Cochineal — red  (Dunker  and  Mag- 
nussen). 

Hematoxylin  alum   (Moosbrugger). 

Gram's  method  —  section  staining 
(Partsch). 

Safranin  in  aniline  oil,  followed  by 
K.  L   (Babes). 

Solution  of  orcein  in  acetic  acid  (Is- 
rael). 

Picrocarmin — fungus,  yellow;  other 
parts,  red  (Baranski). 

The  actinomyces  in  a  section  are  best 
shown  by  Gram's  method,  first  with 
methyl  violet,  then  with  Bismarck 
brown  (Tillmann). 

Cultivation. — It  is  quite  difficult  to 
cultivate  in  coagulated  blood-serum  (O. 
Israel),  coagulated  blood-serum  and 
agar-agar  (Bostrom),  and  coagulated 
egg-albumin  and  agar-agar  (Wolff  and 
J.  Israel). 

INOCULATION.— It  has  been  suc- 
cessfully carried  out  by  James  Israel  and 
Ponfick,  from  tissue  and  from  pure  cul- 
tures. 

Opinions  differ  as  to  its  power  of 
producing  pus,  a  secondary  infection  by 
the  pus-germs  being  thought  the  true 
cause  of  the  pus  sometimes  found  with 
actinomycosis.  Dissemination  by  the 
lymphatic  system  never  occurs.  Glan- 
dular enlargement  indicates  secondary 
infection. 

L  Cutaneous  Surface. — Around  the 
primary  lesion  are  small  secondary  le- 
sions. Two  forms  are  described:  (a) 
The  anthracoid,  which  pursues  a  rapid 
course,  with  fever,  and  sometimes  sep- 
ticemic in  character.  It  is  characterized 
by  flat  tumefaction,  with  multitudes  of 
small  openings  with  yellow  granula- 
tions, from  which  thick  pus  exudes. 
(b)  The  ulcerofungous,  which  pursues 
a  subacute  course,  with  tendency  to 
chronicity.    In  the  face  it  tends  to  form 


ACTINOMYCOSIS    (LAt»LACE). 


m 


burrowing  abscesses  instead  of   recog- 
nizable tumors. 

2.  Bronchial  Tubes  and  Lungs.— 
Some  observers  believe  that  the  peri- 
bronchial lymphatic  vessels  and  glands 
disseminate  the  fungus  or  its  spores  in 
the  lungs ;  when  the  fungus  reaches  the 
lung-tissue  proper,  granulation  tissue  is 
formed,  which,  through  secondary  in- 
fection, suppurates.  Amyloid  degenera- 
tion  of    other    organs    may  occur,  or 


6  00 
Q  a       O 


m^ 


Actinomycotic  growths  in  the  liver 
in  man,  according  to  Crookshank,  have 
a  characteristic  naked-eye  appearance, 
from  their  peculiar  honeycombed  struc- 
ture. The  cases  between  the  fibrous  tra- 
beculc-e  are  full  of  caseous  matter,  in 
which  the  more  or  less  spheroidal 
masses  of  the  fungus  are  imbedded.  In 
museum  specimens,  which  have  been  for 
some  time  preserved  in  spirit,  the  con- 
tents of  the  loculi  may  have  fallen  out, 


H 

m' 


Ray  fungus  {c.c.c),  club-shaped  bodies  {d 
pus  of  actinomycosis. 

metastasis  of  the  disease,  in  case  a  pul- 
monary vein  has  been  pierced.  At  times 
the  pericardium  or  peritoneum  becomes 
affected  (Strlimpell). 

3.  Alimentary  Canal. — In  the  jaws 
the  mass  usually  resembles  a  sarcoma, 
but,  if  incised  before  secondary  infec- 
tion and  suppuration  has  occurred,  the 
reddish  surface  will  be  seen  to  be  inter- 
mingled with  yellowish  spots,  which  are 
collections  of  actinomyces. 

In  the  intestines  the  fungus  causes 
proliferation  of  the  submucous  tissue, 
and  whitish  patches.  External  fistulse 
are  commonly  found. 


,d.d),  and  spores  (a,  a,  a)  found  in  the 
(Poncet  and  Berard, ) 

and  the  honeycombed  appearance  is  then 
much  more  marked  than  in  recent  speci- 
mens. 

The  writer  having  noted  the  fre- 
quency of  the  organisms  in  sputum, 
their  faihire  to  grow  at  other  than 
body  temperature,  and  the  lack  of 
convincing  evidence  that  the  disease 
was  contagious,  these  facts  suggested 
that  the  infection  arose  within  the 
individual.  The  prevailing  location 
of  the  diseases  about  the  jaw  or  neck 
pointed  to  the  mouth  as  the  source 
of  infection.  In  addition,  the  history 
of  much  trouble  with  the  teeth,  pre- 
ceding the  infection,  was  conspicuous 
in  two  of  the  author's  cases  of  acti- 


344 


ACTINOMYCOSIS    (LAPLACE). 


nomycosis.  Following  this  line  of 
thought,  he  made  careful  micro- 
scopic, cultural,  and  biological  exam- 
inations of  the  contents  of  carious 
teeth  removed  in  16  examined  cases. 
In  all  11  cases  by  cover-slip  prepara- 
tions, Gram-staining  filaments  mixed 
with  other  bacteria  were  found.  Se- 
rial sections  studied  in  5  cases  were 
positive.  The  organisms  were  pres- 
ent in  such  numbers  as  to  suggest 
that  they  play  a  fundamental  part  in 
dental  caries.  Lord  (Boston  Med. 
and  Surg.  Jour.,  July  21,  1910). 

PROGNOSIS.— The  prognosis  is  se- 
rious in  proportion  to  the  rapidity  with 
which  suppuration  occurs.  Actinomy- 
cosis of  the  upper  jaw  is  more  serious 
than  actinomycosis  of  the  lower  jaw,  as 
it  has  a  greater  tendency  to  invade  the 
deep  structures.  Internal  actinomycosis 
is  almost  always  fatal,  owing  to  its  in- 
accessibility. External  actinomycosis 
may  cause  death  from  pyemia,  septice- 
mia, and  exhaustion.  When  so  placed 
as  to  be  easily  removed  and  treated 
early  the  prognosis  is  favorable.  A  per- 
manent recovery  usually  follows  a  com- 
plete removal  of  the  primary  focus,  as 
metastasis  is  rare  (Senn). 

Actinomycosis  has  a  pronounced  tend- 
ency to  spontaneous  recovery  except  in 
internal  organs  (Schlange). 

From  an  analysis  of  60  cases  the  fol- 
lowing conclusions  are  reached :  When 
the  disease  involves  the  head  and  neck, 
except  in  a  few  cases  when  the  base  of 
the  skull  is  invaded,  the  course  is  favor- 
able, recovery  taking  place  in  from  three 
to  nine  months.  It  is  exceptional  for 
the  fistula  to  persist  or  to  form  anew 
after  the  lapse  of  a  year.  Pulmonary 
actinomycosis  may  terminate  in  recov- 
ery. The  prognosis  of  actinomycosis  is 
the  more  favorable,  as  the  anterior  ab- 
dominal walls  are  involved  and  the 
posterior  escape.  Death  usually  results 
from  amyloid  degeneration  and  wasting. 


If  actinomycosis  presents  pyemic  mani- 
festations, a  fatal  termination  is  to  be 
expected,  as  a  number  of  vital  organs 
are  likely  to  be  involved.  Actinomy- 
cosis may  pursue  a  chronic  course, 
continuing  thirteen  years  or  longer,  if 
functionally  important  organs  be  not 
involved,  as  when  the  process  confines 
itself  to  the  connective  tissue  about  the 
spinal  column. 

The  prognosis,  as  shown  by  a  study 
of  all  cases  reported,  depends  largely 
upon  the  location  of  the  disease,  the 
pulmonary  cases  showing  the  highest 
mortality,  the  cervicofacial  the  low- 
est. W.  G.  Erving  (Bull.  Johns  Hop- 
kins Hosp.,  Nov.,  1902). 

The  prognosis  is  now  much  better 
than  formerly,  some  cases  recovering 
spontaneously.  If  surgical  treatment 
is  not  possible  the  prognosis  is  grave, 
but  not  always  hopeless.  If  the  dis- 
eased tissue  can' be  reached  it  should 
be  incised,  scraped,  cauterized  with 
nitrate  of  silver  stick,  the  cavity 
packed  with  iodoform  gauze,  and  io- 
dide of  potassium  given  internally  in 
large  doses.  The  X-ray  should  sub- 
sequently be  used.  Bevan  (Annals 
of  Surg.,  May,  1905). 

TREATMENT.— 1.  General.— Po- 
tassium iodide  was  found  useful  in 
animals  by  Thomassen  and  Nocard.  In 
man  it  should  be  thoroughly  tried  before 
surgical  intervention  is  resorted  to,  es- 
pecially when  the  disease  is  so  extensive 
as  to  prevent  complete  removal  by  surg- 
ery. The  results  obtained  from  iodide 
of  potassium  have  been  remarkable  in 
some  cases  and  negative  in  others.  This 
divergence  of  views,  according  to  Fer- 
net, depends  on  the  variation  in  the  vir- 
ulence of  the  disease,  in  its  evolution  in 
different  individuals,  in  the  difference 
existing  in  the  receptivity  of  the  tissues, 
and  on  the  influence  of  secondary  in- 
fective processes.  In  recent  and  purely 
actinomycotic  lesions  the  results  may  be 


ACTINOMYCOSIS    (LArLACE). 


345 


excellent ;  in  old-standing  cases,  and 
■where  the  ray  fungns  is  associated  with 
streptococci,  staphylococci,  and  the  bac- 
terium coli  cominune,  the  drug  treat- 
ment is  less  successful. 

According  to  Berard,  in  two-thirds 
of  the  cases  of  chronic  actinomycosis  of 
the  face  and  neck  the  results  of  iodide, 
treatment  are  /;//.  In  three-fourths  of 
the  recent  cases  recovery  has  been  ob- 
tained by  it,  combined  with  surgical 
treatment,  and  in  one-fourth  by  iodide 
treatment  alone.  Potassium  iodide  can- 
not be  regarded  as  specific  in  actinomy- 
cosis in  man.  If,  at  the  end  of  some 
weeks,  improvement  is  slight  only,  oper- 
ative interference  should  be  carried  out 
at  once. 

The  drugs  which  are  the  most  suc- 
cessful in  pulmonary  actinomycosis,  in 
the  opinion  of  Sabrazes  and  Cabannes, 
are  potassium  iodide  and  eucalyptus. 
If  there  is  any  involvement  of  chest 
wall,  surgical  treatment  should  be 
undertaken. 

Four  cases,  in  one  of  which  the 
tumor  was  situated  below  the  angle 
of  the  scapula.  All  the  patients  were 
given  iodide  of  potassium,  and  the 
wounds  were  treated  with  peroxide, 
tincture  of  iodine  in  full  strength  or 
solution,  and  packed  in  iodoform 
gauze  until  all  evidence  of  presence 
of  the  fungus  had  disappeared.  J.  C. 
Munro  (Boston  Med.  and  Surg.  Jour., 
Sept.  13,  1900). 

The  injection  of  a  5  per  cent,  solution 
of  permanganate  of  potassium  into 
the  cysts  has  been  of  advantage. 

Case  of  actinomycosis  of  the  face 
which  was  cured  by  hot  compresses 
(temperature,  63°  C,  or  145°  F.)  and 
carbolic  acid  injections.  The  first 
dose  of  the  latter  was  12  c.c.  of  a  3 
per  cent,  solution.  The  compresses 
were  continuously  applied  day  and 
night,  being  changed  every  ten  min- 
utes. A.  Strubell  (Miinch.  med. 
Woch.,  May  8,   1900). 


Wiiilc  potassium  iodide  in  connec- 
tion with  the  X-ray  exerts  a  curative 
effect  in  superficial  actinomycosis, 
this  treatment  is,  to  a  great  extent, 
without  avail  in  pulmonary  and  ab- 
dominal involvement.  Hence  copper 
sulphate,  which  is  used  to  destroy  the 
fungi  of  grain  and  other  vegetable 
parasites,  tried  in  doses  of  i/^  to  1 
grain  three  times  a  day.  Good  results 
obtained  both  in  blastomycosis  of 
the  skin,  where  the  copper  is  given 
internally  and  used  as  a  wash  of  1 
per  cent,  strength  for  the  lesions,  and 
in  actinomycosis,  where  it  is  also 
given  by  mouth,  and  a  1  per  cent,  so- 
lution is  employed  in  irrigation  of 
sinuses.  A  mixed  treatment  of  cop- 
per and  iodine  salts  may  prove  most 
effective  in  certain  cases.  A.  D. 
Bevan  (Jour.  Amer.  Med.  Assoc,  May 
20,  1905). 

Great  difference  of  opinion  exists 
as  to  the  value  of  iodide  of  potassium 
in  the  treatment  of  actinomycosis. 
The  important  point  is  to  use  the 
drug  at  a  time  when  there  is  a  chance 
of  eradicating  the  disease.  Cases  in 
the  advanced  stages  of  the  disease 
may  be  benefited  by  its  use,  but  the 
possibility  of  a  cure  is  an  extremely 
remote  one.  Whether  the  simple 
treatment  of  opening  the  abscess  and 
draining  it  would  be  sufficient  for  a 
cure,  it  is  impossible  to  say,  but  in 
this  case  the  fact  remains  that  the 
patient  did  not  begin  to  improve 
until  she  was  thoroughly  under  the 
influence  of  the  drug.  The  action  of 
the  iodide  in  this  disease  is  unknown;  , 
possibly  by  promoting  absorption  of) 
inflammatory  products  as  they  are 
formed  it  may  check  the  spread  of 
the  disease.  So  far  as  known,  it  can 
have  no  specific  action  on  the  organ- 
ism of  actinomycosis.  Iodides  are 
largely  used  in  the  treatment  of  this 
disease  in  veterinary  practice,  and 
many  cures  have  resulted.  Knox 
(Lancet,  Nov.  3,  1906). 

Actinomycosis  of  the  appendix  is 
usually  chronic  and  may  last  for 
years.  If  possible,  the  cecum  and 
neighboring  bowel  should  be  sacri- 
ficed for  a  thorough  removal  of  the 


346 


ACTINOMYCOSIS    (LAPLACE). 


disease.  Usually  all  that  can  be  done 
is  to  open  abscesses  as  they  point, 
and  to  give  internal  remedies,  as  po- 
tassium iodide,  etc.  Short  (Lancet, 
Sept.   14,   1907). 

Six  cases  of  actinomycosis  appar- 
ently cured  by  injections  of  sodium 
cacodylate.  The  infection  originated 
always  from  the  cavity  of  the  mouth, 
with  localization  of  the  abscesses  and 
infiltration  on  the  tongue ;  the  neck, 
with  perilaryngeal  spreading;  in  the 
regio  temporalis,  with  spreading  to 
the  base  of  the  skull,  and  of  the  lower 
jaw,  with  spreading  to  the  submaxil- 
lary glands.  On  the  first  day  a  10  per 
cent,  watery  solution  (^  of  a  Pravaz 
syringeful)  was  injected  intramus- 
cularly in  the  nates,  increasing  each  day 
J4  syringeful  until  a  full  syringeful 
is  given  during  one  week,  and  then 
decreasing  the  quantity  to  the  Y^ 
syringeful,  and  then  commencing 
over.  The  local  measures  are  con- 
fined to  puncture  or  little  incisions 
for  abscesses.  More  extensive  opera- 
tions are  avoided.  Foederl  (Zen- 
tralbl.  f.  Chin,  Bd.  xxxv,  p.  45,  1908). 

Experience  in  56  cases  in  which 
treatment  was  by  iodide  alone,  with 
34  cures;  94  with  operation  alone, 
with  75  cures;  109  with  excision  plus 
iodide,  wnth  60  cures,  and  30  in  which 
treatment  was  by  other  measures, 
with  25  cures.  All  but  46  of  the  cured 
patients  have  been  re-examined  re- 
cently. The  writer  calls  attention  to 
the  fact  that  the  deaths  during  the 
years  since  were,  in  many  cases,  re- 
ported as  having  been  due  to  tuber- 
culosis, while  there  is  a  possibility 
that  the  supposed  tuberculosis  may 
have  been  merely  a  metastasis  in  the 
lung  from  the  old  actinomycotic  in- 
j^fection  in  some  of  these  cases.  His 
conclusions  from  a  review  of  nearly 
300  cases  are  that  actinomycosis, 
when  circumscribed,  should  be  re- 
sected like  any  other  tumor.  If  this 
is  not  possible,  or  if  the  afifection  is 
diffuse,  he  advocates  administration 
of  sodium  iodide  internally,  with 
partial  resection.  His  experience  in 
one  case  encourages  further  trials  of 
tuberculin    in    actinomycosis,   as    the 


cure  in  this  case  can  be  ascribed,  he 
thinks,  only  to  the  course  of  tuber- 
culin treatment.  The  iodide  does  not 
require  such  large  dosage  as  some  ad- 
vocate; his  preference  is  for  1  Gm. 
the  first  day,  2  Gm.  the  second,  3  Gm. 
the  third  (from  15  to  45  grs.),  repeat- 
ing the  same  succession  after  suspen- 
sion for  three  days.  Sometimes  he 
gave  from  2  to  5  Gm.  a  day  in  pow- 
ders, supplemented  by  local  applica- 
tions of  a  10  per  cent,  solution  of 
sodium  iodide.  Maier  (Beitrage  z. 
klin.  Chir.,  June,  1909). 

2.  Surgical.— Local  measures  which 
do  not  completely  remove  the  infected 
tissues  do  harm,  as  they  frequently  give 
rise  to  secondary  infection,  rapid  exten- 
sion, and  death. 

Cauterization  with  solid  silver  nitrate 
in  actinomycosis  of  skin  and  soft  parts 
in  which  suppuration  and  fistulous 
tracts  have  occurred  possesses  a  specific 
action  on  the  actinomycosis  (Kottnitz). 

3.  Electrotechnical. — Two  platinum 
needles,  attached  to  the  two  poles  of  a 
constant-current  battery,  are  to  be  in- 
serted into  the  tumor.  Through  the 
two  needles  a  current  of  50  milliam- 
peres  is  to  be  passed,  while  every  min- 
ute some  drops  of  a  10  per  cent,  iodide 
of  potassium  solution  are  to  be  injected 
into  the  mass.  The  solution  is  decom- 
posed into  nascent  iodine  and  potas- 
sium. This  is  repeated  every  eight  days, 
each  session  lasting  twenty  minutes,  un- 
der an  anesthetic  (Gautier). 

Before  suppuration  all  diseased  tis- 
sues, glands,  etc.,  should  be  removed 
and  the  parts,  when  possible,  cauterized 
with  the  thermocautery. 

After  suppuration  the  parts  should  be 
treated  as  if  they  were  tuberculous, 
curetting  and  packing  with  iodoform 
gauze. 

Ernest  Laplace, 

Philadelphia. 


ACTOL.         ACUPUNCTURE.  ACUTE    RHINITIS    (SCARLETT).         347 


ACTINOTHERAPY.    Sec  Light. 

ACTIVE  HYPEREMIA.    See 

Ihi'EREMiA,  Bier's  Treatment  by. 

ACTOL  or  silver  lactate,  occurs  in 
the  form  of  a  white  powder,  odorless  and 
almost  tasteless,  which  is  soluble  in  15  parts 
of  water.  Its  color  is  changed  when  ex- 
posed to  the  light.  Applied  to  the  tissues,  it 
causes  coagulation  of  the  proteids,  in  com- 
mon with  the  nitrate  of  silver. 

THERAPEUTICS.— Actol  has  marked 
antiseptic  and  disinfectant  properties,  ac- 
cording to  the  strength  of  solution  used.  In 
solutions  of  1  in  500  to  200  it  is  used  as  an 
antiseptic  for  wounds.  For  infected  wounds 
it  may  be  employed  as  a  disinfectant  in 
stronger  or  even  saturated  solutions.  But 
little  discomfort  is  caused  when  the  powdered 
silver  lactate  is  applied  to  open  surfaces.  It 
is  claimed  to  have  a  deep-seated  effect  "by 
penetration  to  the  subjacent  tissues,  though 
known  to  be  decomposed  into  other  com- 
pounds when  in  contact  with  the  superficial 
cells.  Actol  has  also  been  used' internally  as 
an  antiseptic.  It  has  been  found  effective 
in  diminishing  intestinal  putrefaction,  at  the 
same  time  causing  a  tendency  to  constipation. 
Some  have  even  employed  it  internally  and 
hypodermically  for  a  general  antiseptic  action- 
throughout  the  organism.  Sixteen  grains 
(1  Gm.)  have  been  injected  subcutaneously 
without  serious  results.  S. 

ACUPUNCTURE.—  This  proced- 
ure  is  principally  used  for  the  relief  of 
tension  in  edematous  or  congested  tissues. 
It  is  especially  useful  in  edema  of  the  scro- 
tum, labia,  and  extremities  when  the  tissues 
are  sufficiently  distended  to  threaten  slough- 
ing. Acupuncture  is  also  employed  for  the 
relief  of  pain  in  neuritis  and  muscular  rheu- 
matism, especially  in  sciatica  and  lumbago ; 
the  benefit  afforded,  when  such  is  obtained, 
is  due  mainly  to  reflex  contraction  of  the 
blood-vessels  "t)f  the  area,  thus  reducing  the 
congestion  of  the  nervi  nervorum  and  the 
sensory  terminals  to  which  the  pain  is  due. 
In  edema,  the  benefit  is  the  direct  result  of 
the  abstraction  of  considerable  blood-serum 
imprisoned  in  the  tissues. 

TECHNIQUE.  — The  instruments  em- 
ployed are  a  very  small  narrow-bladed  bis- 
toury and  surgeons'  needles.    The  part  should 


be  carefully  sterilized  by  first  washing  it  with 
soap  and  water  and  then  bathing  it  with  alco- 
hol or  a  1 :  2000  solution  of  mercury.  The 
operator's  hands  and  instruments  should  like- 
wise be  carefully  sterilized.  These  pre- 
cautions are  very  important  in  view  of  the 
fact  that  edematous  tissues  are  readily  in- 
fected. If  the  patient  is  very  sensitive  to 
pain,  the  part  may  be  anesthetized  with  ethyl 
chloride. 

For  edematous  tissues  the  small  bistoury 
is  the  better  instrument,  one  or  two  stabs,  or, 
in  large  areas,  many  such,  being  practised, 
avoiding  blood-vessels.  A  compress  dipped 
in  a  warm  5  per  cent,  solution  of  boric  acid 
is  then  applied  to  encourage  escape  of  the 
serum.  These  must  be  frequently  changed 
and  the  tissues  kept  very  clean,  as  otherwise 
fetor  soon  appears. 

For  muscular  rheumatism,  especially  lum- 
bago, a  number  of  round  needles  are  thrust 
into  the  painful  area  from  1  to  2  inches, 
according  to  the  fat  overlying  the  part,  and 
left  in  situ  from  five  to  ten  minutes.  The  pain 
often  ceases  at  once.  Great  care  should  be 
taken,  on  withdrawing  the  needles,  not  to 
break  them,  lest  fragments  remain  in  the 
tissues.  '  In  neuritis,  sciatica,  etc.,  the 
needles,  several  of  them  are  thrust  into  the 
nerve  sheath  at  intervals  (not  a  difficult  pro- 
cedure in  large  nerves)  and  ^eft  in  situ  about 
five  minutes.  A  fine  hypodermic  needle  may 
be  used,  among  the  ordinary  needles,  with 
advantage,  in  the  same  way,  and  increase  the 
efficiency  of  the  treatment  by  being  used  to 
inject  a  little  sterile  water,  which  acts  as 
an  analgesic,  or,  if  the  pain  be  very  severe, 
morphine.  This  treatment  is  efficacious  in 
most  instances  where  other  measures  have 
failed.  S. 

ACUTE    RHINITIS,    OR 

ACUTE  CORYZA— DEFINI- 
TION.— An  acute  inflammatory  condi- 
tion of  the  nasal  mucous  membrane,  in 
which  repeated  attacks  predispose  to 
the  extension  of  the  inflammation  to 
the  neighboring  cavities,  as  the  pharynx ; 
the  larynx ;  the  lower  air  passages ;  and 
to  a  lesser  degree,  to  the  accessory 
sinuses  of  the  nose. 

SYMPTOMATOLOGY.— The  ear- 
liest manifestation  of  an  acute  rhinitis 


348 


ACUTE    RHINITIS    (SCARLETT). 


is  a  sensation  of  dryness  or  irritation 
in  tlie  nose,  which  later  becomes  of  an 
itching,  tickhng,  or  stinging  character. 
\"ery  often  the  attack  is  ushered  in  by  a 
preliminary  chill  or  "z  creepy  feeling." 
Sneezing  is  an  early  symptom,  and  is 
soon  followed  by  a  sensation  of  fullness 
in  the  nose,  with  subsequent  obstruction 
to  nasal  breathing,  and  a  dull  throbbing 
headache  over  the  site  of  the  accessory 
cavities.  A  general  feeling  of  illness, 
with  aching  in  the  limbs  and  back,  fre- 
quently prevails.  The  sense  of  smell 
and  taste  are  interfered  with.  Hearing 
is  often  markedly  impaired,  owing  to 
the  involvement  of  the  mucous  mem- 
brane at  the  orifice  of  the  Eustachian 
tube,  or  the  extension  of  the  inflamma- 
tion through  the  tube  into  the  middle 
ear.  The  voice  is  also  altered  and 
assumes  a  nasal  intonation.  There  is  a 
noticeable  loss  of  resonance  v/hich 
characterizes  the  normal  voice,  and  the 
sounds  of  w  and  11  cannot  be  readily 
produced.  The  skin  is  dry  and  at  times 
becomes  hot  from  the  presence  of  fever. 
Thirst  and  anorexia  are  also  asso- 
ciated symptoms.  The  urine  is  scant 
and  high  colored.  The  existing  consti- 
pation is  usually  responsible  for  the 
presence  of  the  furred  tongue.  The 
eyelids  are  more  or  less  swollen  from 
the  existing  congestion,  and  a  profuse 
lachrymation  is  not  infrequently  present 
from  the  extension  of  the  inflammation 
through  the  nasolachrymal  duct.  The 
membrane  of  the  nose  is  red,  swollen, 
dry,  and  glazed,  and  is  unduly  sensitive. 
The  nasal  passages  are  practically  oc- 
cluded by  the  swelling  of  the  membrane 
and  the  erectile  tissue  of  the  turbinates 
to  the  capacity  of  the  fossae,  thereby 
greatly  interfering  with  the  normal 
physiological  functions  of  the  nose,  as 
well  as  with  that  of  deglutition.  Owing 
to    this    existing    obstruction,    nursing 


infants  at  times  manifest  considerable 
difficulty  in  obtaining  sufficient  nourish- 
ment. 

The  nasal  discharge  at  first  is  scant, 
or  it  may  be  entirely  absent,  but  it  soon 
becomes  copious,  is  clear,  and,  owing  to 
the  presence  of  an  excessive  amount  of 
salines  in  its  composition,  it  becomes 
very  irritating  to  the  skin  of  the  upper 
lip  and  the  nasal  alse;  in  fact,  the  irri- 
tation not  infrequently  becomes  so 
marked  as  to  cause  excoriation,  or  even 
cracking,  of  the  bordering  cutaneous 
surfaces.  This  condition,  no  doubt,  is 
often  very  much  aggravated  by  the 
frequent  use  of  the  handkerchief. 

As  the  disease  progresses,  the  dis- 
charge becomes  opaque,  mucopurulent 
in  character,  thick  and  tenacious,  and 
of  a  greenish-yellow  color.  A  micro- 
scopic examination  of  the  discharge 
shows  a  marked  increase  in  the  corpus- 
cular elements. 

No  sharp  line  of  demarcation  exists 
between  the  second  and  the  terminal 
stages  of  this  disease.  In  three  or  four 
days  the  discharge  gradually  becomes 
thicker  and  scantier;  the  swelling  of 
the  membrane  subsides;  the  constitu- 
tional manifestations  gradually  lessen 
and  finally  disappear;  the  special  senses 
assume  their  normal  activity,  and  in 
the  course  of  a  week  or  ten  days  all 
traces  of  the  disease  disappear. 

A  significant  feature  of  acute  rhinitis 
is  the  possibility  of  the  antrum  of  High- 
more,  the  frontal  sinus,  the  ethmoid  or 
the  sphenoid  cells,  the  Eustachian  tube, 
or  the  middle  ear  becoming  the  seat  of 
disease  as  the  result  of  the  extension  of 
the  inflammatory  process.  The  naso- 
pharynx and  the  pharynx  invariably 
become  involved,  partly  through  the 
extension  of  the  inflammation  by  con- 
tinuity* and  partly  from  the  interference 
with  the  normal  function  of  the  nose. 


ACUTE    RHINITIS    (SCARLETT). 


349 


DIAGNOSIS. — The  recognition  of 
this  condition,  as  a  rule,  is  seldom 
fraught  with  many  difficulties,  and  the 
diagnosis  in  most  cases  is  usually  made 
with  considerable  ease.  It  is  important, 
however,  to  guard  against  the  possibil- 
ity of  a  mistake  by  making  careful  in- 
quiry into  the  history  of  the  attack,  and 
also  by  making  a  cautious  examination 
of  the  nasal  cavities  in  order  to  distin- 
guish between  a  simple  acute  catarrh 
and  a  rhinitis  as  the  result  of  measles, 
influenza,  nasal  diphtheria,  hereditary 
syphilis,  a  foreign  body,  a  tumor,  and 
iodism.  Cases  of  measles  and  in- 
fluenza will  invariably  show  a  higher 
temperature  and  greater  constitutional 
disturbances,  and  in  the  former  case 
the  appearance  of  the  rash  will  elimi- 
nate all  doubt  of  the  cause  of  the  exist- 
ing nasal  condition.  Nasal  diphtheria 
can  be  recognized  by  the  existence  of 
the  characteristic  grayish  membrane  in 
the  anterior  nares  and  in  the  throat, 
associated  with  the  usual  constitutional 
symptoms.  In  the  absence  of  the  mem- 
brane, strong  evidence  of  the  condition 
continues  to  exist  in  the  blood-tinged 
discharge,  but  a  positive  diagnosis  can 
be  obtained  only  by  culture.  The 
"snuffles"  of  hereditary  syphilis  is  usu- 
ally found  in  very  young  children,  with 
concomitant  symptoms  of  this  infec- 
tion, i.e.,  malnutrition,  glandular  en- 
largement, and  in  older  children  the 
characteristic  Hutchinson's  teeth.  A 
foreign  body  or  a  tumor  can  be  detected 
on  examination,  and  in  cases  of  iodism 
a  careful  history  will  elicit  the  fact  that 
a  considerable  quantity  of  the  drug  has 
been  taken. 

Cases  of  acute  rhinitis  are  occasion- 
ally encountered  in  which  the  causative 
agent  is  some  chemical  irritant.  The 
diagnosis  should  not  be  difficult,  as  con- 
stitutional symptoms  are  rarely    resent ; 


the  duration  of  the  attack  is  seldom,  if 
ever,  as  long  as  the  ordinary  cases ;  and 
with  the  withdrawal  of  the  cause  the 
condition  invariably  subsides. 

The  patient  seldom  seeks  treatment 
for  acute  rhinitis  much  before  the  end 
of  the  first  or  the  beginning  of  the 
second  stage  of  the  disease,  and  then 
gives  a  history  of  exposure,  quickly 
followed  by  the  nasal  discomfort  and 
the  rapid  development  of  the  disease. 
This  history,  in  conjunction  with  the 
more  or  less  characteristic  appearance 
of  the  conditions  within  the  nasal 
chambers,  will  usually  be  sufficient 
evidence  for  a  positive  diagnosis. 

ETIOLOGY.— Predisposing  Causes. 
— If  careful  observation  were  made  in 
each  case  of  acute  rhinitis,  it  would,  no 
doubt,  frequently  be  seen  that  the  at- 
tack occurs  when  the  resisting  powers 
of  the  body  are  below  par.  Under 
normal  conditions  a  certain  equilibrium 
is  maintained  for  the  production  and 
the  elimination  of  the  waste  products  of 
the  body;  but,  when,  for  some  reason, 
the  normal  function  of  this  apparatus  is 
interfered  with  and  there  occurs  a 
faulty  elimination  of  the  waste  products 
or  an  overproduction  of  the  same,  body 
resistance  is  lowered  and  susceptibility 
to  disease  becomes  more  marked.  This 
condition  is  undoubtedly  often  en- 
couraged by  indiscreet  action  of  the 
patient  in  regard  to  diet,  causing  digest- 
ive disturbances,  torpid  liver,  and  con- 
stipation, in  which  the  consumption  of 
food  is  out  of  proportion  to  the  com- 
bustion, thus  causing  an  autotoxemia, 
in  which  there  is  sometimes  a  marked 
evidence  of  uric  acid.  It  is  at  this  time 
that  a  coryza  may  be  considered  the 
nasal  signal  of  systemic  poisoning,  for 
the  blood  will  be  found  tainted  with 
the  products  of  faulty  oxidation.  Strong 
evidence  of  this  condition  will  also  be 


350 


ACUTE    RHINITIS    (SCARLETT). 


found  in  the  examination  of  the  urine, 
in  which  uric  acid  or  mixed  urates  will 
be  present. 

With  such  lowered  resistance,  one 
becomes  easily  affected  by  conditions 
such  as  prolonged  confinement  in  an  ill- 
ventilated  room,  extreme  physical  ex- 
haustion following  overwork,  or  a  se- 
vere mental  strain.  A  lowered  nerv- 
ous tone;  interference  with  the  normal 
activity  of  the  sudoriferous  glands, 
and  the  absence  of  a  natural  coverinsr 
for  the  head,  as  in  baldness,  are  oft- 
times  important  predisposing  factors. 

Acute  coryza  is  the  result  of  a  triple 
pathogenetic  alliance — a  chronic  rhinitis, 
a  chronic  intestinal  toxemia,  and  an 
exposure  to  an  accidental  stress  of 
some  kind,  not  necessarily  thermo- 
metric  or  hydrometric,  for  just  as 
effective  as  these  are  others  of  an 
emotional,  dietetic,  dynamic,  or  micro- 
bic  nature.  Although  in  all  cases  the 
general  principles  of  treatment  will  be 
the  same,  considerable  discrimination 
in  the  matter  of  detail  must  be  exer- 
cised in  the  individual  case,  because  of 
the  varying  nature  of  the  exciting  cause. 
Grayson    (Therap.  Gaz.,  May,  1909). 

It  is  not  uncommon  to  find  in  some 
patients  showing  a  disposition  to  fre- 
quent colds  some  underlying  patholog- 
ical condition  within  the  nose,  such  as 
deviation  of  the  septum,  a  stenosis,  or  a 
hypertrophic  rhinitis,  thus  causing  the 
current  of  air  to  be  misdirected  in  such 
a  way  as  to  act  as  an  irritant  upon  a 
more  or  less  sensitive  membrane,  which 
is  usually  below  par  as  the  result  of 
recurrent  attacks. 

When  frequent  and  persistent  attacks 
occur  in  childhood,  a  careful  examina- 
tion of  the  nasopharynx  will  sometimes 
show  the  causal  agent  to  be  the  exist- 
ence of  adenoids.  Acute  rhinitis  is  not  in- 
frequently found  in  infants  under  three 
months  and  those  who  are  sufferinsf 
from  malnutrition,  as  in  rachitis.    It  is 


also  thought  by  a  noted  pediatrist  to  be 
a  complication  of  dentition.  In  suscep- 
tible children,  the  cause  is  often  very 
trivial.  A  curious  fact  exists  in  that 
this  affection  is  seldom  found  in  old 
people. 

An  hereditary  tendency  seems  quite 
apparent  in  some  cases,  notably  in  chil- 
dren. In  the  majority  of  cases,  how- 
ever, the  direct  cause  can  be  traced  to 
an  improper  mode  of  living.  The  child 
gets  very  little  fresh  air;  is  confined 
in  a  room  which  is  improperly  venti- 
lated, usually  overheated;  the  windows 
of  the  bedroom  are  kept  carefully 
closed  at  night  for  fear  the  child  may 
catch  cold;  the  clothing  is  very  often 
in  excess  of  what  is  really  needed,  thus 
making  it  impossible  for  the  individual 
to  indulge  in  any  active  play  with- 
out producing  a  profuse  perspiratiom 
Under  these  conditions  the  mucous 
membrane,  especially  of  the  nose  and 
throat,  soon  becomes  very  sensitive  and 
the  child  is  a  frequent  sufferer  of  colds. 

Evidence  sometimes  point  to  such 
chronic  conditions  as  asthma,  hay  fever, 
rheumatism,  tuberculosis,  and  syphilis 
as  being  factors  in  the  production  of 
acute  rhinitis.  Attacks  in  some  persons 
can  be  attributed  only  to  their  idiosyn- 
crasy. Excessive  sexual  indulgence 
often  shows  a  predisposition  to  pro- 
voke an  attack,  as  do  gastric  and  in- 
testinal diseases,  and  a  neurotic  tend- 
ency. Thermic  and  climatic  condi- 
tions are  sometimes  to  be  considered. 

Exciting  Causes. — Although  certain 
depraved  conditions  of  the  body  may  be 
said  to  predispose  to  attacks  of  acute 
rhinitis,  usually  there  are  certain  causes 
to  which  the  attack  may  be  definitely 
attributed.  Exposure  to  cold  and  wet 
when  the  body  is  overheated ;  exposure 
to  sudden  or  extreme  changes  in  the 
atmosphere;   the   wetting   of   the    feet 


ACUTE    RHINITIS. (SCARLETT). 


351 


when  the  system  is  debihtated  from 
other  diseases;  or  the  chihing  of  the 
body  from  any  cause,  especially  as  the 
result  of  sitting  in  such  a  position  as  to 
allow  a  draft  of  air  to  strike  the  back 
of  the  neck  or  head.  This  seems  to 
support  the  theory  advanced  by  some 
that  the  impression  of  cold  on  certain 
parts  of  the  body  produces  an  inhibi- 
tory effect  upon  the  vasomotor  nerves 
controlling  the  blood  supply  of  the  nasal 
mucous  membrane. 

The  inhalation  of  certain  irritating 
chemical  fumes,  such  as  those  of  iodine, 
chlorine,  bromine  and  hydrochloric  acid 
may  result  in  a  coryza.  Sometimes  the 
mere  inhalation  of  irritating  dust  may 
produce  an  attack.  Foreign  bodies  in 
the  nose ;  or  certain  drugs,  as  ipecac 
and  the  iodides,  may  produce  the  same 
effect.  Wagner  is  of  the  opinion  that 
the  inflammation  is  not  infrequently  the 
result  of  migration  of  bacteria  from 
diseased  tonsils.  The  examination  of 
the  nasal  secretion  often  shows  the 
"presence  of  a  variety  of  micro-organ- 
isms, chief  among  which  are  the  Micro- 
coccus catarrhalis,  the  Bacillus  septus, 
the  Bacillus  Friedldnder,  and  the  Bacil- 
lus segmcntosus  of  Cautley. 

There  are  several  kinds  of  organisms 
capable  of  causing  a  cold.  This  term 
does  not,  therefore,  answer  to  one 
specific  malady,  but  connotes  several 
distinct  maladies  which  it  is  convenient 
to  group  together  under  a  generic  name. 
Among  the  more  common  "cold"  organ- 
isms are  the  following :  Friedlander's 
bacillus ;  the  Bacillus  septicus;  the 
bacillus  of  influenza;  the  Micrococcus 
catarrhalis.  These  organisms  give  rise 
in  the  susceptible  to  specific  febrile  dis- 
orders; but,  unlike  the  exanthemata, 
these  disorders  do  not  confer  immunity 
for  more  than  a  very  limited  period, 
sometimes  for  not  more  than  a  few 
weeks.  Campbell  (Practitioner,  Oct., 
1909). 


The  evidence  seems  indicative  that 
the  diphtheroids,  particularly  Bacillus 
segmcntosus  of  Cautley,  are  concerned 
in  the  production  of  so-called  common 
cold  in  its  typical  manifestations  in  the 
nose,  and  there  is  much  evidence  that 
it  occurs  in  epidemic  form.  The  Micro- 
coccus catarrhalis  is  much  more  general 
in  its  manifestation,  and  is,  probably, 
also  epidemic  and  prodiictive  of  a  rather 
more  severe  inflammation,  though  mild 
epidemics  occur.  It  seems  likely  that 
the  symbiosis  of  these  two  organisms 
increase  the  virulence.  The  pneumo- 
bacillus  of  Friedlander  is  much  more 
concerned  in  chronic  conditions  and  is 
probably  identical  with  the  ozena  bacil- 
lus. The  pneumococcus  of  Frankel 
flourishes  in  any  part  of  the  upper  re- 
spiratory tract  and,  when  virulent,  has 
been  found  in  pure  culture.  Clinically, 
the  segmcntosus  infection  is  most  likely 
to  be  in  the  nose,  seldom  in  the  trachea, 
but  may  cause  otitis  media ;  Micro- 
coccus catarrhalis  is  most  apt  of  all  to 
invade  the  larynx  and  trachea,  but  may 
occur,  in  the  ear  or  nose  and  with 
variable  virulence.  The  pneumobacil- 
lus  is  mostly  confined  to  the  nose  and 
sinuses.  Influenza  is  conspicuous  by  its 
absence.  Pyogenic  cocci  are  non-patho- 
genic locally,  except  as  secondary  in- 
vaders, and  the  probability  is  that  only 
a  limited  number  of  strains  are  con- 
cerned in  causation  of  acute  infections 
of  the  mucosa,  and  these  are  not  gen- 
uine coryza.  The  bacterial  flora  of  the 
nose  in  America  probably  do  not  differ 
materially  from  those  of  other  coun- 
tries, but  must  of  necessity  be  governed 
largely  by  environment,  occupation, 
social  position,  and  epidemics  as  to  the 
ratios  of  finding.  W.  Walter  (Jour. 
Amer.  Med.  Assoc,  Sept.  24,  1910). 

Whenever  the  disease  is  at  all  preva- 
lent, suspicion  arises  as  to  the  pos- 
sibility of  it  being  contagious  or  pro- 
duced by  some  infectious  material  in 
the  air.  It  not  infrequently  ushers  in 
an  attack  of  bronchitis,  laryngitis,  or 
one  of  the  acute  infections,  such  as 
influenza,  measles,  t3^phoid  fever,  small- 
pox, or  whooping-cough. 


352 


ACUTE    RHINITIS    (SCARLETT). 


PATHOLOGY.— An  acute  rhinitis 
is  characterized  by  the  same  patho- 
logical changes  which  take  place  in  in- 
flammation of  the  mucous  membrane 
elsewhere  in  the  body,  and  may  be  con- 
sidered in  three  stages. 

Stage  of  Engorgement. — During  this 
stage  the  mucous  membrane  is  swollen 
and  rather  dark  in  color.  The  normal 
secretion  at  first  is  decreased,  or  even 
entirely  arrested,  and  there  occurs  a 
proliferation  of  the  epithelium.  If  the 
microscope  could  be  used  at  this  time, 
the  blood-vessels  would  be  seen  to  be 
markedly  dilated  and  there  would  be 
more  or  less  stasis  of  the  blood-stream, 
permitting  the  adhesions  of  leucocytes 
to  the  blood-vessel  walls.  Their  final 
penetration  into  the  surrounding  tissue 
is  the  beginning  of  the  next  stage. 

Stage  of  Exudation.— With  the  mi- 
gration of  the  leucocytes  into  the 
interstitial  tissue,  there  is  also  a  tran- 
sudation of  altered  blood-serum  and  a 
forcing  out  of  erythrocytes.  The  dis- 
charge that  follows  is  usually  profuse ; 
at  first  it  is  a  mixture  of  mucus  and 
serum,  but  this  soon  becomes  of  a 
mucopurulent  type  and  finally  purulent. 

Stage  of  Resolution. — This  is  char- 
acterized by  the  restoration  of  the 
normal  function  of  the  mucous  glands, 
the  secretion  from  which  causes  the  dis- 
charge to  become  thicker  and  more 
opaque.  The  exudate  within  the  mu- 
cosa is  gradually  absorbed,  the  lost 
epithelium  in  time  is  replaced  by  new 
cells,  and  the  membrane  is  slowly  re- 
duced to  its  normal  size. 

PROGNOSIS.— This  depends  upon 
the  severity  of  the  attack  and  the  extent 
to  which  the  tissues  are  involved.  The 
simple  cases  usually  recover  in  the 
course  of  a  few  days  to  a  week  without 
any  detrimental  results.  In  some  few 
cases,    however,    certain    changes    may 


take  place  in  the  tissues  and  increase 
their  tendency  to  recurrent  attacks. 
The  prognosis  becomes  less  favorable 
for  an  early  recovery  if  the  inflamma- 
tion should  extend  into  any  one  of 
the  accessory  cavities  of  the  nose  and 
cause  a  suppurative  process,  or  if  there 
should  occur  an  involvement  of  the 
middle  ear  by  extension  through  the 
Eustachian  tube. 

TREATMENT.— The  treatment  of 
acute  rhinitis  may  be  prophylactic, 
abortive,  or  curative,  depending  upon 
the  cause  of  the  attack.  Persons  who 
show  a  predisposition  to  recurrent  at- 
tacks of  coryza  should  guard  the  body 
against  such  conditions  as  favor  their 
onset.  The  protective  agencies  of  the 
body  should  be  strengthened  by  regular 
and  systematic  exercise,  especially  in 
the  open  air,  and  should  be  of  the 
nature  of  horseback  riding,  golf,  ten- 
nis, or  something  as  vigorous.  Gray- 
son recommends,  instead  of  medicine, 
good  vigorous  exercise  several  times 
a  day,  claiming  that  "the  quickened 
capillary  circulation  and  vigorous  action 
of  the  sweat  glands  that  accompany 
hard  exercise  are  incomparably  more 
beneficial  than  the  merely  passive  leak- 
age that  follows  the  use  of  diaphoretic 
drugs.  If  in  addition  to  this  an  abun- 
dance of  water  is  drunk  and  the  supply 
of  food  is  greatly  reduced — almost 
stopped  in  fact — we  may  look  for  an 
amelioration  of  all  the  coryza  symp- 
toms in  a  much  shorter  time  than  if  our 
main  reliance  is  vested  in  quinine,  bella- 
donna, and  opium  combinations,  that 
have  had  too  long  a  vogue." 

Proper  discretion  in  diet  should  be 
practised,  particularly  by  those  who  are 
victims  of  uric  acid  diathesis.  Cold 
bathing,  gradual  at  first,  is  an  effi- 
cient stimulant  to  the  relaxed  vascular 
system.    Proper  selection  of  underwear 


ACUTE    RHINITIS    (SCARLETT). 


353 


and  clothing,  especially  for  outdoor 
service,  should  be  made. 

If  the  patient  is  seen  in  the  early- 
stages,  in  the  first  few  hours,  the  attack 
may  be  abbreviated,  or  the  duration,  at 
least  lessened,  if  the  proper  treatment 
is  immediately  instituted.  The  patient 
should  be  given  a  mustard  foot-bath, 
4  grains  of  quinine,  10  grains  of 
Dover's  powder,  a  hot  lemonade,  and 
then  put  to  bed  with  a  liberal  covering 
of  bedclothes  to  encourage  free  per- 
spiration. This  should  be  followed  by 
active  catharsis.  The  above  treatment 
will  usually  necessitate  the  keeping  of 
the  patient  in  the  house  at  least  the 
following  day. 

Recent  investigations  lead  to  the  be- 
lief that  the  isolation  of  the  predomi- 
nating organism  from  the  nasal  secre- 
tion and  the  injection  into  the  patient 
of  a  vaccine  product  from  the  same 
will  frequently  abort  an  attack,  and 
even  establish  a  certain  degree  of  im- 
munity for  a  short  period  of  time.  The 
earlier  the  injection,  the  more  decided 
will  be  the  result. 

By  means  of  vaccine  therapy,  not  only 
are  we  able  to  cut  short  an  acute  cold, 
but  also  to  confer  considerable  im- 
munit}'-  against  future  attacks.  By  this 
method  we  can,  further,  often  suc- 
cessfully treat  colds  which  have  be- 
come chronic,  e.g.,  chronic  rhinitis, 
laryngitis,  bronchitis,   etc. 

In  but  few  cases  of  common  cold  can 
a  stock  vaccine  be  employed  with  much 
hope  of  success;  except  in  the  case  of 
the  Bacillus  septus  we  are  not  likely 
to  do  good  by  any  vaccine  other  than 
that  prepared  from  the  patient's  own 
person.  Having  secured  the  specimen 
it  is  forwarded  to  an  expert,  and  the 
vaccine  can  be  prepared  ready  for  use 
within  forty-eight  hours  of  its  receipt. 
The  best  time  for  the  injection  is  the 
evening,  and  the  best  spot  the  flank 
slightly  above  and  internal  to  the  an- 
terior   superior    spine.     If   the   reaction 


is  pronounced  it  may  be  necessary  to 
keep  the  patient  in  bed  for  twenty-four 
hours.  Campbell  (Practitioner,  Oct., 
1909). 

Early  convalescence  and  the  return 
of  the  normal  vigor  will  be  augmented 
by  the  administration  of  tonics,  strych- 
nine and  quinine  being,  two  of  the 
favorite  remedies.  After  two  or  three 
days  this  treatment  is  not  sufficiently 
efficacious  and  curative  measures  will 
have  to  be  resorted  to. 

The  usual  run  of  cases  can  be  cured 
without  confining  the  patient  to  the 
house,  unless  the  weather  is  severe.  In 
children,  however,  an  attack  which  may 
be  considered  mild  in  an  adult  may  be 
severe  enough  to  confine  the  young 
patient  to  bed.  On  the  first  visit  of  a 
case  of  acute  rhinitis,  especially  if  early 
in  the  disease,  the  nasal  discharge  will 
be  found  thin  and  acid,  and  the  mucous 
membrane  markedly  swollen.  Reduc- 
tion in  the  size  of  the  turbinal  bodies 
can  be  obtained  by  the  application  of  a 
1  per  cent,  solution  of  cocaine  and  a 
1 :  10,000  solution  of  the  suprarenal 
extract. 

A  solution  of  2  per  cent,  cocaine  and 
2^4  per  cent,  antipyrin  often  acts  to 
greater  advantage  in  these  cases,  as 
the  latter  remedy  prevents  a  violent 
reaction  and  frequently  prolongs  the 
contraction. 

In  patients  who  are  sufferers  from 
gout,  the  cocaine  will  invariably  fail  to 
produce  the  desired  reduction  of  the 
mucous  membrane,  but  relief  may  be 
obtained  by  the  free  administration  of 
colchicum. 

Cocaine  should  be  used  with  the 
greatest  care  in  infants,  as  they  are 
particularly  susceptible  to  its  detri- 
mental effects.  Weak  solutions  are 
permissible,  however,  when  the  symp- 
toms are  severe  and  the  infant  is  pre- 


1—23 


354  ACUTE    RHINITIS    (SCARLETT). 

vented  from  nursing.   Powders  contain-  On  the  other  hand,  Weitlauer,  of 

ing  cocaine  are  often  prescribed  for  Innsbruck,  commends  the  internal  use 

adults;    but    it    has    caused    cocaino-  of  sodium  salicylate,  combined  with 

mania  in  so  many  cases  that  it  should  Dover's  powder,  which,  it  is  said,  will 

only  be  applied  by  the  physician  him-  afford  relief  one  hour  after  beginning 

self  with  an  insufflator  to  cause  con-  treatment: — 

traction  of  the  mucosa  and  the  effect         IJ  Sodium   salicylate Sj  (30 Gm.). 

kept  by  means  of  a  powder  containing  Dover's  powder  gr.  xlv  (3  Gm.). 

no  cocaine  which  the  patient  can  use  ^^'''[  '/  P'PP'rmint...  luJ  (0.06 c.c). 

pt;  '^niiff  '^°  ^^  divided  into  20  powders,  1  of  which 

is  to  be  taken  in  a  little  water  every  three  or 

For  use  by  the  physician  the  follow-  fom-  hours. 

ing  is  efficient :—  Aromatic    spirit    of    ammonia    and 

IJ,  Cocaine  hydrochloride,  s^ee^  spirit  of  niter  are  recommended 

Camphor    aa  gr.  j  (0.065  Gm.).  n      ^             ^     ^      u   ■,       j_„            i, 

n  ,      .     ,                     ^-wor-     ^  as  excellent  agents  to     abort     a  cold 

Pulverised    sugar 3ij  (8(jm.).  s' 

Morphine  hydro-  by  Beverley  Robinson. 

chloride gr.  j  (0.065  Gm.).  One    or    two    doses    of    1    Gm.     (15 

Pulverised  acacia,  grains)     each    of    acetylsalicylic    acid. 

Bismuth  subnitrate .aa.  5j  (4Gm.).  taken  at  the  first  indication  of  an  on- 

Pulverised   mallow...   Siss  (6Gm.).  coming  cold  in  the  head,  will  arrest  it. 

_            1                               ,.          ^      1       .  The  drug   is    especially   effectual   when 

Enousfh  to  cover  a  dime  to  be  in-  .,      ^    ,    ,•  ,  ,•       •     ,,      ,.       .   •     r  i, 

^                              _  the   first  tickhng   m   the  throat  is    felt 

sufflated  in  each  nostril.  toward  evening,  and  the  drug  is  taken 

Ointments    may   also   be   used    con-  then  and  again  in  the  morning.     This 

veniently  by  the  physician,  by  means  permits  him  to  go  about  his  surgical 

of  a  flat  probe.    Lemoine  recommends  f'^f     ^^^er     breakfast     without     any 

^   .  further  symptoms  of  coryza.     If  acute 

the  following  formula :—  rhinitis   has    developed   or  the   coryza 

IJ  Cocaine  hydrochloride,  relapses,    two    or    three    further    doses 

Salol    aa  gr. %  (0.021  Gm.).  always  cured  it  completely.     The  drug 

Menthol    gr.  ss  (0.032  Gm.).  probably  does  not  act  on  the  bacteria, 

Boric  acid   5ss(2Gm.).  but   it   seems   to   enhance   the   resisting 

Petrolatum    B]  (30  Gm.).  powers   of   the  tissues.      Sick    (Miinch. 

..,,..,                      .  med.  Woch.,  July  16,  1912). 
A  piece  the  size  of  a  large  pea  is 

applied  with  the  probe  to  the  swollen  'At  home  the  patient  should  be  in- 

mucosa  in  each  nostril.  structed  to  use  one  of  the  well-known 

Insufflations  may  be  made  with :—  cleansing  sprays,  such  as  Dobell's  solu- 

U.  Calomel,  tion,    glycothymoline,    or    a    solution 

Morphine  hydro-  made  from  Seiler's  tablets. 

chloride  aa  gr. %  (0.01  Gm.).  A  very  useful  and  economical  solu- 

Bismuth  subnitrate  ..  Siiss  (10 Gm.).  ^^^^  jg  prepared   by   dissolving  a   tea- 

To     sustain     the     effect     Rudaux,  spoonful  of  salt  in  a  pint  of  water— 

Grosse  and  le  Lorier  recommend  the  practically  a  normal  salt  solution— and 

instillation  into  each  nostril,  night  and  using  it  freely  in  the  nose, 

morning,  of  several  drops  of  the  fol-  I"  using  any  cleansing  solution,  great 

lowing  solution :—  ^^^^  s^°^^^  ^^  exercised  m  blowing  the 

_.„,,,                         ^r  /AAcr^     N  nose  directly  afterward,  for  when  it  is 

^.  Eucalyptol   gr.  %  (0.05  Gm.).  .       ,        i,                    r  ^          ,   ^• 

Sterilised  liquid  ^one  too  harshly  some  of  the  solution 

vaselin   Bj  (30 c.c).  mixed  with  the  nasal  secretion  may  be 


ACUTE    RHINITIS    (SCARLETT). 


355 


blown  into  the  middle  ear  through  the 
Eustachian  tulje  and  set  up  an  inflam- 
mation with  the  formation  of  an 
abscess. 

Following  the  cleansing,  the  inflamed 
mucous  membrane  may  be  protected  by 
an  oily  solution  composed  of : — 

B  Menthol, 

Camphor    aa  gr.  v  (0.3  Gm.). 

Liq.    albolcne fSij  (60c.c.)- 

•This  is  to  be  sprayed  in  the  nose,  or 
several  drops  may  be  placed  in  each 
nostril,  and  snuffed  up,  several  times  a 
day.  If  it  is  found  impossible  to  drop 
the  solution  in  the  nose  of  a  child,  the 
application  may  have  to  be  made  by  a 
brush. 

Another  useful  combination  is : — 

B  Menthol   gr.  viiss  (0.5  Gm.) . 

Phenylsalicylate 3ss  (2.0  Gm). 

Boric  acid   Sij  (8.0  Gm.). 

M.  fiat  pulvis. 

Since  the  swelling  of  the  mucous 
membranes  renders  the  snuffing  up  of 
the  powder  difficult,  the  patient  will 
find  it  advantageous  to  use  a  piece  of 
rubber  tubing  about  20  cm.  long;  the 
powder  is  placed  in  it  at  one  end,  and 
air  blown  through  from  the  other  end 
by  the  mouth. 

An  excellent  agent  to  keep  the 
swelling  of  the  mucosa  down  is  the 
adrenalin  ointment  1 :  1000,  a  piece  as 
large  as  a  pea  being  applied  in  each 
nostril. 

During  the  early  stage  of  the  disease, 
when  the  nasal  discharge  is  watery,  one 
of  the  coryza  tablets  on  the  market  can 
be  used  to  good  advantage  to  dry  up  the 
excessive  secretion.  This  is  particu- 
larly advantageous  to  those  who  are 
compelled  to  appear  in  public,  A  very 
satisfactory  comibination  is  the  one 
devised  and  recommended  by  Dr.  S. 
MacCuen  Smith,  which  is  made  up  as 
follows : — 


I^  Atropine  sul- 
phate      gr.  %oo  (0.0001  Gm.) . 

Strychnine  sulphate, 

Arsenous  acid. iia  gr.  1/^40  (0.00027  Gm.). 

Morpliine  sul- 
phate      gr.  i/ioo  (0.0006  Gm.) . 

Quinine  sulphate,  gr.  Yio  (0.006  Gm.). 

Powd.    camphor.  gT.%  (0.016  Gm.). 

By  the  time  six  of  these  are  taken,  at 
half-hour  intervals,  a  dryness  in  the 
throat  will  be  noticed.  Only  half  of 
one  should  be  given  to  a  child  of  five 
years.  Notwithstanding  their  known 
value  among  the  laity,  the  indiscrimi- 
nate use  of  these  tablets  should  not  be 
encouraged,  for  their  administration  at 
a  time  when  the  nasal  discharge  has 
become  inspissated  renders  the  patient 
much  more  uncomfortable  and  the  dis- 
charge more  difficult  of  expulsion. 

In  the  third  stage,  when  the  mem- 
brane is  relaxed  and  the  epithelium  is 
being  shed  more  rapidly  than  it  should, 
a  spray  composed  of  20  to  60  minims 
of  the  distilled  extract  of  hamamelis  to 
the  ounce  of  water  may  be  used  to  good 
advantage. 

It  seems  almost  needless  to  state  that 
the  diet  in  all  cases  of  acute  rhinitis 
should  be  restricted  at  the  beginning  of 
the  attack,  but  as  convalescence  takes 
place  it  can  gradually  be  increased  and 
finally  restored  to  its  normal  status. 

In  those  cases,  and  especially  is  this 
true  in  children,  where  there  is  a  tend- 
ency to  excoriation  of  the  upper  lip  and 
the  nostril,  these  exposed  cutaneous 
surfaces  should  be  protected  from  the 
irritating  effect  of  the  discharge  by  the 
application  of  vaselin  or  some  simple 
ointment. 

A  mixture  of  menthol  and  chloro- 
form, equal  parts,  is  very  efficacious. 
A  few  drops  of  the  mixture  are  placed 
upon  a  handkerchief  and  inhaled 
through  the  nostril.  It  causes  the  ob- 
struction in  the  nose  to  immediately 
disappear,     A   few  drops  may  also  be 


356 


ADDISON'S    DISEASE    (LANGLOIS). 


placed  in  a  cupful  of  hot  water  and  the 
vapor  inhaled.  (Les  Nouveaux  Reme- 
des,  March  24,  1910). 

Sodium  salicylate  causes  a  cold  to 
abort  if  taken  within  twenty-four  to 
thirty-six  hours.  Single  dose  of  7>^ 
grams  (0.5  dram)  often  suffices.  Taken 
later,  it  relieves  symptoms  and  shortens 
attack.  It  is  also  valuable  in  the 
chronic  coryza  of  gouty  subjects. 
Should  be  taken  after  eating  and  pref- 
erably in  small  doses,  dissolved  in  half 
a  glassful  of  water.  Courtade  (Revue 
de  therap.,  Jan.  1.  1910). 

RuFus  B.  Scarlett, 

Philadelphia. 

ADDISON'S  DISEASE— In  1855, 
Addison  pointed  out  in  a  historic  mon- 
ograph ("On  the  Constitutional  and 
Local  Effects  of  Disease  of  the  Supra- 
renal Capsules")  the  relations  between 
a  disease  known  as  "bronzed  skin"  or 
"bronzed  cachexia"  and  lesions  of  the 
adrenal  bodies.  The  interest  excited 
by  this  work  at  once  called  forth  nu- 
merous observations  on  the  subject, 
and,  while  a  certain  number  of  the 
papers  lent  support  to  the  idea  of  close 
relationship  between  the  lesion  of  the 
adrenals  and  the  syndrome  which  Addi- 
son described,  in  others  a  contrary 
opinion  was  expressed.  In  the  year 
succeeding  the  publication  of  his  first 
monograph,  Addison  brought  out  a 
paper  in  which  he  described  a  lesion  of 
the  semilunar  ganglia  unaccompanied 
by  changes  in  the  adrenals. 

We  can  thus  state  that  it  was  Addi- 
son himself  who  originated  the  two 
theories  which  are  still  brought  into 
requisition  to  explain  the  manifesta- 
tions of  the  bronzed  disease :  the 
theory  of  adrenal  insufficiency  and  the 
nervous  theory.  Before  discussing 
these  hypotheses,  a  study  of  the  dis- 
ease itself  from  the  clinical  aspect 
must  first  be  made. 


SYMPTOMS.  — When  Trousseau 
proposed  that  the  term  "Addison's  dis- 
ease" be  applied  to  the  affection  de- 
scribed by  the  Scotch  physician  under 
the  name  "bronzed  skin,"  he  specifically 
designated  "a  singular  cachexia  espe- 
cially characterized  by  the  bronzed 
hue  assumed  by  the  integument."  We 
therefore  feel  justified  in  including 
under  the  term  Addison's  disease  only 
those  affections  which  are  of  the 
"bronzed  disease"  types,  and  not  the 
aggregate  of  all  the  conditions  resulting 
from  functional  disturbances  of  the  ad- 
renals, i.e.,  "without  melanodermia,  no 
Addison's  disease."  The  disease,  even 
thus  limited,  still  presents  a  number  of 
clinical  forms  showing  rather  well- 
marked  special  characteristics. 

Asthenia. — The  patient  is  generally 
unable  to  state  the  exact  period  of  on- 
set of  the  affection.  In  typical  cases 
the  pathological  state  is  almost  always 
one  of  adrenal  tuberculosis  which  has 
invaded  these  organs  secondarily,  the 
patient  is  already  in  the  wasting  stage 
of  tuberculosis,  and  it  is  difficult  to 
recognize  the  new  symptoms.  Where 
there  is  primary  adrenal  tuberculosis, 
however,  the  symptomatology  is  more 
characteristic.  Asthenia  dominates  the 
whole  picture.  The  least  physical  effort 
is  followed  by  extreme  lassitude.  At 
first  the  patient  is  still  capable  of  ener- 
getic and  rapid  muscular  activity,  but 
he  is  not  equal  to  sustained  work ; 
fatigue  at  once  appears ;  later,  as  the 
process  advances,  lassitude  becomes 
constant  and  the  patient  thinks  of  but 
one  thing — avoiding  the  slightest  exer- 
tion and  remaining  in  bed  in  the  dorsal 
decubitus.  The  mere  ingestion  of  food 
requires  an  effort  beyond  the  patient's 
strength,  and  the  administration  of 
solid  food  becomes  difficult. 

The  earliest  writers  had  been  struck 


ADDISON'S    DISEASE    (LANGLOIS). 


357 


by  the  asthenia  of  Addison's  (hscase, 
and  Jaccoud  gave  an  excellent  descrip- 
tion of  it.  lUit  the  exact  conditions 
under  \vhicli  this  fatigue  occurs  were 
learned  through  the  labors  of  Langlois, 
Charrin,  and  Abelous,  who  explained  it 
on  the  basis  of  a  new  conception  of  its 
pathogenesis.  The  study  of  muscular 
fatigue  with  the  ergograph  of  IMosso 
permits  of  differentiating  the  resistance 
in  an  ordinary  case  of  tuberculosis  from 
that  in  one  of  Addisonian  phthisis. 
The  simple  tuberculous  subject  will 
continue  lifting  the  weight  of  the  ergo- 
graph  for  two  minutes,  performing 
total  work  equal  to  1150  grammeters ; 
the  Addisonian  subject,  after  having 
lifted  the  weight  just  as  energetically 
during  the  earlier  contractions,  becomes 
fatigued  very  soon  and  stops  exhausted 
before  the  second  minute,  having  per- 
formed work  equal  to  only  750  gram- 
meters.  If  the  weight  to  be  lifted  is 
placed  at  2  kg.,  fatigue  already  ap- 
pears at  the  fifth  contraction  and  the 
sum  of  work  done  is  practically  nil. 

Mclanodcrmia,  or  bronzing,  from 
wdiich  symptom  the  disease  received  its 
earliest  appellation,  often  does  not  de- 
velop until  after  the  asthenia.  It  ap- 
pears most  frequently  in  the  form  of 
small,  browmish  macules  scattered 
over  the  entire  skin-surface,  though 
most  marked  at  certain  points  of 
election.  The  scrotum  and  labia 
majora,  which  are  normally  pig- 
mented, very  frequently  present  a 
characteristic  color.  The  mucous 
membranes  are  very  often  affected 
before  the  skin.  The  internal  sur- 
taces  of  the  cheeks,  the  labial  com- 
missures, as  well  as  the  genital 
mucous  membranes,  should,  always 
be  examined  in  asthenic  subjects. 

The  melanodermia  may  remain  local- 
ized, and  this  is,  indeed,  more  usually 


the  case,  but  ir  may  also  become  gen- 
eralized through  confluence  of  the  pri- 
mary patches  and  involve  the  whole  of 
the  integument,  making  the  patient's 
skin  appear  truly  like  that  of  a  mulatto, 
though  never  like  that  of  a  full-blooded 
negro.  Erault  points  out  that  the  palms 
and  soles  are  not  involved,  but  these 
areas  are  imperfectly  or  not  at  all  pig- 
mented in  negroes,  and  even  in  the 
anthropoid  apes  the  soles  of  the  feet 
remains  of  a  pink  color. 

Case  of  Addison's  disease  in  a 
woman,  aged  37,  who  complained  of 
cough  with  expectoration  and  gen- 
eral weakness.  The  first  sign  was  a 
very  striking  pigmentation  of  the 
skin.  The  color  was  yellowish  brown, 
and  affected  chiefly  the  forehead, 
neck,  hypochondriac  and  abdominal 
regions  in  front,  and  tl.e  infra- 
scapular  and  lumbar  regions  be- 
hmd.  The  arms  were  uniformly  pig- 
mented from  the  shoulder  to  the 
metacarpophalangeal  joints.  There 
was  an  entire  absence  of  pigment 
over  the  clavicular  and  mammary  re- 
gions in  front,  and  the  suprascapular 
region  behind.  Scattered  here  and 
there  through  the  pigmented  areas 
are  patches  varying  in  size  from  a 
lentil  to  a  walnut,  of  clear,  pearly 
skin.  The  pigmented  areas  were  not 
raised  above  the  surface,  nor  were 
they  affected  by  scraping  with  the 
nail  or  sharp  instrument.  The  thighs 
and  legs  were  free  from  pigment. 
The  pigment  was  more  marked  over 
the  areolae  and  axillary  regions.  There 
was  evidence  of  consolidation  over 
the  left  apex,  where  there  were  relative 
dullness  to  percussion,  diminution  of 
respiratory  murmur,  some  tubularity, 
and  a  few  dry  and  moist  rales.  The 
lungs  were  otherwise  normal.  The 
symptoms  in  their  order  of  develop- 
ment were  pigmentation  of  the  skin, 
great  weakness  accompanied  by 
breathlessness,  cough  with  expectora- 
tion, anemia,  and,  lastly,  a  tendency 
to  diarrhea.  McKendrick  (Glasgow 
Med.  Jour.,  June,  1909). 


358 


ADDISON'S    DISEASE    (LANGLOIS). 


Case  of  Addison's  disease  in  a 
male,  aged  31,  in  whom  exposure  to 
the  sun  darkened  the  pigmentation, 
which  involved  the  axillae,  elbows, 
nipples,  breast,  the  pubis,  gums,  lips, 
tongue.  Of  late  the  nails  have  be- 
come a  dark  brown.  A.  F.  Chace 
(Post-Graduate,  Feb.,  1911). 

Traumatism  of  the  skin  is  a  predis- 
posing cause  to  pigmentation.  The 
earliest  melanodermic  patches  are 
often  noted  to  appear  over  old  cica- 
trices, especially  over  the  healed  areas 
of  former  blisters,  and  even  the  appli- 
cation of  a  blister  or  merely  of  a 
poultice  on  an  asthenic  subject  is 
often  sufficient  to  cause  a  sudden 
outburst  of  pigmentation  and  permit 
a  positive  diagnosis  of  Addison's 
disease. 

Gastrointestinal  disturbances  are  fre- 
quent, but  very  variable  in  nature.  At 
the  outset,  constipation  is  the  rule,  and 
is  accompanied  by  anorexia,  which  may 
be  accounted  for  both  by  the  intestinal 
paresis  and  by  the  general  lassitude  to 
which  we  have  already  alluded.  The 
constipation  may  be  succeeded,  par- 
ticularly in  the  acute  forms,  by  atonic 
diarrhea.  But  the  most  characteristic 
symptom  is,  without  doubt,  vomiting. 
Preliminary  nausea  is  very  seldom 
present;  the  vomiting  comes  on  sud- 
denly, and  generally  in  the  morning 
upon  awaking.  At  first  the  patient's 
stomach  is  evacuated  but  once  a  day ; 
then,  as  the  disease  progresses,  the 
vomiting  becomes  more  frequent  and 
occurs  at  intervals  during  the  day. 
The  act  takes  place  with  but  little 
muscular  effort,  of  which  the  subject 
is,  indeed,  incapable.  The  vomitus  is' 
colorless,  thin,  and  consists  of  mucus. 

Circulatory  disturbances  are  of  great 
importance.  The  earlier  observers  had 
already  pointed  out  a  special  weakness 
of   the   pulse,   together   with   all   the 


symptoms  of  cerebral  anemia.  There- 
searches  of  Schafer  and  Oliver  and  of 
Langlois  and  the  later  investigations 
of  the  action  of  adrenalin  served  to 
direct  the  attention  of  clinicians  to 
these  disorders,  at  the  same  time  dis- 
closing their  pathogenesis. 

The  Addisonian  subject  is  in  a  state 
of  hypotonicity.  By  reason  of  the  ab- 
sence or  insufficiency  of  the  adrenal 
secretion,  the  normal  tonus  of  the  ves- 
sels is  no  longer  maintained.  Even  at 
the  outset  of  the  affection,  along  with 
the  first  signs  of  asthenia,  lowered 
arterial  tension  is  to  be  found.  The 
sphygmomanometer  shows  100  to  120 
mm.  of  mercury.  The  fall  in  pres- 
sure is  accentuated  as  the  disease 
advances;  in  the  last  stages,  a  tension 
as  low  as  50  mm.  may  be  noted. 

Bernard  and  Sergent  have  brought 
out  a  clinical  phenomenon  which  they 
claim  to  be  useful  in  diagnosis  without 
the  aid  of  instruments  of  precision, 
viz.,  the  "adrenal  white  line" — as  op- 
posed to  the  red  line  of  meningitis.  To 
cause  it  to  appear,  the  skin  of  the 
abdomen  is  lightly  rubbed  with  the  pulp 
of  a  finger,  without  scratching;  after  a 
few  moments  a  rather  broad  white 
streak  appears,  which  becomes  more 
and  more  marked,  remains  stationary 
for  three  to  four  minutes,  then  grad- 
ually fades  off. 

Pain  and  Nervous  Disturbances. — 
Lumbar  and  abdominal  pains  of  great 
severity  may  be  present  at  the  outset  of 
the  disease.  They  frequently  become 
localized  in  the  epigastric  and  hypo- 
chondriac regions,  and  Martineau  has 
described  a  pathognomonic  seat  of  pain 
at  the  anterior  extremity  of  the  eleventh 
rib.  These  pains,  however,  almost 
characteristic  when  they  are  sudden  in 
onset,  are  sometimes  entirely  wanting 
throughout  the  course  of  the  disease. 


ADDISON'S    DISEASE    (LANGLOIS). 


359 


When  considering  the  pathogenesis  of 
the  affection,  we  shall  find  it  easy  to 
understand  how  the  variations  ob- 
served in  the  painful  phenomena  may 
be  explained  according  to  the  extent 
and  the  seat  of  lesions  surrounding  the 
adrenals. 

We  have  already  mentioned  the  as- 
thenic manifestations,  which,  according 
to  us,  are  referable  rather  to  the  mus- 
cular system  than  to  the  nervous  sys- 
tem proper,  or  at  least  to  the  structure 
which  unites  the  nerve  with  the  mus- 
cle— the  terminal  plate  (as  formerly 
designated)  or  the  receptive  substance 
of  Langley.  True  paralyses  are  rare 
and  in  no  sense  characteristic.  Cere- 
bral disturbances,  such  as  the  pros- 
tration, the  tinnitus  aurium,  the  hal- 
lucinations, and  especially  the  en- 
cephalopath)^  of  Addison's  disease, 
may  be  due  to  two  causes :  cere- 
bral anemia  resulting  from  vascular 
hypotonicity,  and  intoxication  either 
through  suppression  of  the  antitoxic 
activity  of  the  adrenals  or  through 
the  formation  of  toxic  products  owing 
to  functional  deficiencies — asthenia,  hy- 
potonicity, etc. 

Case  of  Addison's  disease  with  ter- 
minal mental  symptoms  in  a  woman 
of  47  years  of  age,  who  had  been  suf- 
fering two  years  from  Addison's  dis- 
ease. She  became  fretful,  discour- 
aged, showed  diminution  of  volitional 
impulses,  incapacity  for  mental  effort, 
and  mental  defect.  She  also  had 
ideas  apparently  dependent  upon  par- 
esthesia of  the  skin,  i.e.,  that  animals 
were  crawling  upon  her,  that  a  dog 
had  bitten  her  upon  the  arm,  that  a 
searchlight  was  being  played  upon 
her  back,  etc.  The  patient  dying  af- 
ter a  sojourn  of  eighteen  days  in  the 
hospital,  the  author  was  able  to  make 
a  complete  autopsy  with  microscop- 
ical examination.  There  was  healed 
tuberculosis  in  the  lungs,  and  the  ad- 
renals showed   advanced  tuberculous 


degeneration,  bacilli  being  found  in 
the  debris.  H.  W.  Miller  (Amer. 
Jour,  of  Insanity,  Jan.,  1907). 

General  Disturbances. — The  muscu- 
lar and  vascular  weakness  are  neces- 
sarily followed  by  disorders  of  a  gen- 
eral nature.  The  chemical  interchanges 
are  reduced,  the  phenomena  of  assimi- 
lation greatly  retarded,  whence  result 
marked  wasting  of  the  tissues  and  a 
strongly  manifested  sensation  of  cold 
generally  accompanied  by  hypothermia. 
According  to  the  view  of  Sajous,  who 
considers  Addison's  disease  as  char- 
acterized by  deficient  oxidation  and 
lowered  metabolism,  a  study  of  the 
temperature  should  enable  us  to  judge 
of  the  degree  of  adrenal  insufficiency. 

The  blood  in  cases  of  Addison's  dis- 
ease presents  nothing  peculiar.  The 
search  for  pigment  in  the  blood-plasma 
has  always  proved  negative.  Gener- 
ally the  blood-cells  show  diminution, 
but  observations  on  this  subject  have 
been  contradictory.  While  Laignel- 
Lavastine  described  diminutions  of 
the  corpuscles  to  three  millions, 
Loeper  and  Crouzon  found  a  polycy- 
themia. Langlois,  in  a  comparative 
study  of  two  tuberculous  cases  pre- 
senting similar  pulmonary  lesions, 
but  one  of  whom  showed  distinct 
Addison's  disease,  observed  no  dif- 
ference either  in  the  hemoglobin 
percentage,  the  number  of  cells  or 
the  proportion  of  leucocytes.  The 
two  patients  gave  identical  results. 

The  secretion  of  urine  is  diminished 
because  of  the  lowered  tonicity.  Cola- 
santi  and  Bellati,  who  made  a  study  of 
the  urine  of  an  Addisonian  patient  for 
eighteen  days,  found  its  toxicity  above 
that  of  norrhal  urine.  Langlois  did  not 
find  this  abnormal  toxicity  in  the  two 
subjects  of  which  he  made  a  compara- 
tive study. 


360 


ADDISON'S    DISEASE    (LANGLOIS). 


Course  and  Termination. — Addison's 
disease  always  terminates  fatally,  but 
its  course  may  be  more  or  less  rapid. 
Sometimes  the  destruction  of  the  adre- 
nals is  so  quickly  produced  that  the 
morbid  phenomena  show  very  rapid 
progression.  Asthenia  is  present  al- 
most from  the  outset,  the  circulatory 
disturbances  at  once  become  very, 
marked,  and,  lastly,  the  gastrointes- 
tinal disorders,  which  do  not  appear 
to  be  closely  related  to  the  adrenal 
insufficiency,  may  become  of  such 
severity,  with  intractable  vomiting- 
and  diarrhea,  that  cachexia  and  death 
supervene  before  the  melanodermia 
has  had  time  to  declare  itself. 

In  the  cases  having  a  slow  course,  the 
disease  may  remain  stationary  for  a 
long  time,  and  it  is  in  such  cases  that 
are  sometim.es  observed  temporary  pe- 
riods of  improvement  not  only  with 
regard  to  the  digestive  tract,  but  also 
in  the  symptoms  of  melanodermia : 
asthenia  and  arterial  tension.  The 
cause  of  such  periods  of  improvement 
it  is  difficult  to  state. 

We  shall  lay  no  stress  on  the  mode 
of  death  by  progressive  cachexia,  which 
presents  nothing  peculiar,  but  must 
dwell  with  some  emphasis  upon  the 
form  of  death  which  takes  place  rapidly 
or  even  suddenly. 

The  rapid  fatal  termination  in  Addi- 
son's disease  takes  on  the  features  of 
an  acute  intoxication.  The  abdominal 
pains  show  marked  exacerbation;  diar- 
rhea becomes  profuse  and  vomiting 
continuous,  the  blood-pressure  at  the 
same  time  showing  progressive  reduc- 
tion. 

In  some  cases  hypothermia  is  ob- 
served, with  a  tendency  to  collapse ;  in 
others,  on  the  contrary,  there  occurs 
hyperthermia  accompanied  by  delir- 
ium and  convulsions. 


Case  of  acute  Addison's  disease  in 
which  the  duration  of  the  disease 
was  seventeen  days.  The  onset  was 
marked  by  severe  abdominal  pain 
and  vomiting.  There  was,  at  times. 
watery  diarrhea.  Ten  days  later  red- 
dish discoloration  of  the  skin  ap- 
peared over  various  points  of  pres- 
sure. These  later  assumed  a  more 
brown  color.  There  was  no  pigmen- 
tation of  the  mucous  membranes. 
The  blood-pressure  remained  105 
mm,  Hg.,  until  the  day  of  the  death, 
when  it  fell  to  99  mm.  The  clinical 
diagnosis  was  malignant  tumor  of 
the  lungs,  pyloric  stenosis,  and  tumor 
in  the  right  lumbar  region.  The 
symptoms,  pigmentation,  asthenia, 
psychical  disturbance,  and  sudden 
death,  also  suggested  Addison's  dis- 
ease. Autopsy  showed  scirrhous  car- 
cinoma of  the  pylorus  with  multiple 
metastases.  Both  adrenal  glands 
were  involved,  but  only  to  a  very 
moderate  degree.  The  most  striking 
lesion  of  the  adrenals  was  a  general 
venous  thrombosis,  the  apparent  age 
of  which  corresponded  well  with  the 
duration  of  the  symptoms.  The 
writer  believes  that  the  obstruction 
to  venous  outflow  was  the  etiological 
factor  in  the  case.  Straub  (Deut. 
Archiv  f.  klin.  Med.,  Bd.  xcvii,  S.  67, 
1909). 

To  explain  this  sudden  aggravation 
in  the  course  of  the  affection,  several 
hypotheses  have  been  put  forth.  That 
one  which  appears  to  us  the  most  ad- 
missible among  them  is  based  on  a  sud- 
den diminution,  sometimes  even  on  al- 
most complete  suppression,  of  the  func- 
tion or  rather  the  functions  of  the 
adrenals.  Almost  always,  indeed,  such 
an  unfavorable  turn  in  the  disease  suc- 
ceeds upon  an  intercurrent  infection. 
Now,  since  the  researches  of  Charrin 
and  Langlois,  •  followed  by  those  of 
Loeper  and  others,  it  has  been  known 
that  certain  infections,  such  as  diph- 
theria and  scarlatina,  exert  a  selective 
action  on  the  adrenal  glands,   causing 


ADDISON'S    DISEASE    (LANGLOIS). 


36i 


in  them  a  more  or  less  marked  func- 
tional tleliciency.  It  is  thus  plain  that 
if  in  a  gland  already  the  seat  of  tuber- 
culosis, but  which,  nevertheless,  suffices 
to  insure  the  adrenal  function,  a  fresh 
lesion  appears  to  destroy  the  surviving 
cellular  elements  the  symptoms  of  ad- 
renal insufficiency  will  show  a  sudden 
outburst  and  be  seen  in  all  their  inten- 
sity. Boinet  has  also  laid  stress  on  the 
appearance  of  serious  accidents  after 
excessive  fatigue.  Such  occurrences 
confirm  the  investigations  of  Abelous 
and  Langlois  and  of  Albanese  upon  the 
influence  of  fatigue  on  experimentally 
decapsulated  animals. 

Another  theory  accounts  for  the  ag- 
gravating effect  of  intercurrent  infec- 
tions from  the  fact  that,  the  antitoxic 
action  of  the  adrenals  against  certain 
toxins  no  longer  being  exerted,  the 
accidents  due  to  intoxication  are  more 
severely  manifested.  It  is  evident  that 
this  hypothesis  explains  better  than  the 
former  the  phenomena  of  excitation, 
viz.,  delirium,  convulsions,  fever. 

■Sadden  death,  or  at  any  rate  death 
taking  place  within  a  few  minutes,  is 
not  rare  in  the  bronzed  disease,  and 
Addison  had  already  referred  to  such 
a  termination  in  his  monograph.  In 
1896  Ihler  was  able  to  collect  18  cases, 
and  since  that  time  numerous  instances 
have  been  noted.  Certain  cases  of  sud- 
den death  in  apparently  healthy  persons 
have  defied  explanation  until  the  au- 
topsy disclosed  a  tuberculous  or  can- 
cerous process  of  the  adrenals. 

The  advent  of  death  may  be  truly 
fulminating;  a  patient  previously  ex- 
hibiting no  signs  of  aggravation  in  his 
condition  may  drop  dead  while  getting 
out  of  bed  or  on  attempting  to  lift 
a  chair.  The  patient  of  Dupaigne- 
Beclere,  who  was  among  the  first  to  be 
treated  with  relative  success  by  opo- 


therapy, died  suddenly  in  bed  during 
her  convalescence.  In  some  cases  the 
end  is  marked  by  symptoms  of  a  more 
striking  character,  such  as  a  sudden 
attack  of  severe  vomiting,  convulsions, 
etc.  The  pulse  becomes  frequent  and 
thready ;  the  face  cyanosed ;  dyspnea 
develops,  and  death  occurs. 

Accidental  syncope,  nervous  shock, 
acute  intoxication,  and  sudden  adrenal 
insufficiency  have  all  been  advanced  as 
hypotheses  in  explanation  of  such  oc- 
currences. It  is  difficult  to  believe,  in 
this  connection,  that  adrenal  insuffi- 
ciency can  produce  so  rapid  an  effect, 
since  it  is  well  known  that  completely 
decapsulated  animals  survive  for  fifteen 
to  eighteen  hours  and  show  progress- 
ively increasing  intensity  before  death. 
It  appears  to  us  more  reasonable  to 
attribute  the  termination  to  nervous 
shock  originating  in  the  adrenal  or  peri- 
adrenal  sympathetic  nerves,  and  react- 
ing on  the  general  organism  with  its 
cardiac  and  vascular  inefficiency  result- 
ing from  decreased  tonic  activity  on  the 
part  of  the  adrenals. 

Case  of  Addison's  disease  in  a  ne- 
gress,  aged  55  years.  The  face  and 
backs  of  the  hands  and  fingers  were 
intensely  black — much  blacker  in  hue 
than  other  parts  of  the  body.  The 
palms  of  the  hands  were  also  abnor- 
mally pigmented,  but  to  a  lesser  de- 
gree than  the  face.  There  were  nu- 
merous irregularly  defined  areas  of 
pigmentation  on  the  mucous  mem- 
brane of  the  cheek,  gums,  and  tongue. 
Her  pulse  was  frequent,  small,  and 
regular. 

At  the  necropsy  the  vagina  showed 
evidence  of  chronic  inflammation  of 
its  mucous  membrane  and  presented 
patches  of  pigmentation  similar  in 
character  to  those  present  in  the 
mouth.  On  the  vulva  were  a  few 
small  leucodermic  areas.  Both  supra- 
renals  were  enlarged  and  exhibited 
caseous    masses    in    their    substance. 


362 


ADDISON'S    DISEASE    (LANGLOIS). 


apparently  affecting  the  cortex.  Their 
capsules  were  much  thickened  and 
adherent  to  the  surrounding  parts. 
They  contained  caseating  masses,  at 
the  margin  of  which  were  giant  cells, 
in  the  cortex.  The  condition  was 
tubercular,  with  marked  tendency  to 
caseation.  R.  Seheult  (Lancet,  Aug. 
3,  1907). 

Three  cases  of  Addisonism  occur- 
ring in  the  same  family,  in  sisters, 
aged  9,  6,  and  314  years,  respectively. 
The  father,  mother,  and  an  elder  sis- 
ter, aged  19  years,  were  all  healthy. 
The  case  of  the  girl  aged  9  years  was 
one  of  true  Addison's  disease,  with 
prostration,  asthenia,  typical  pigmen- 
tation, low  blood-pressure,  and  occa- 
sional vomiting.  The  other  two  cases 
showed  only  the  typical  pigmentation 
and  low  blood-pressure.  Addison's 
disease  is  very  rare  in  children  under 
13  years  of  age.  Croom  (Lancet, 
,  Feb.  27,  1909). 

Clinical  Varieties. — Several  forms  of 
Addison's  disease  have  been  described 
according  to  the  relative  prominence 
of  certain  symptoms.  These  include 
the  gastrointestinal  form,  painful 
form,  melanodermic  form,  and  as- 
thenic form.  These  divisions  are 
worthy  of  acceptance  because  they 
correspond  in  each  case  to  a  develop- 
ment and  pathogenesis  dififering  from 
the  others.  It  seems  probable,  indeed, 
that  in  the  melanodermic  as  well 
as  in  the  painful  form  sympathetic 
changes  predominate  from  the  outset, 
while,  in  the  asthenic  form,  adrenal 
insufficiency  is  the  primary  cause. 

Addison's  disease  in  infancy  is  not 
rare,  occurring  in  sucklings  as  well 
as  in  later  months.  Most  cases  are 
due  to  tuberculosis  of  the  adrenals, 
although  some  cases  have  been  asso- 
ciated with  the  perfectly  normal 
glands.  The  most  important  symp- 
tom is  pigmentation  of  the  skin,  al- 
though pigmentation  may  be  brought 
about  by  a  long-continued  diarrhea 
in  infants.     Other  symptoms  are  gen- 


eral depression  and  extreme  weak- 
ness, diarrhea  and  vomiting,  and 
convulsions.  The  pulse  is  v/eak  and 
irregular.  The  disease  is  always  fatal, 
dissolution  being  due  to  weakness,  or 
to  some  intercurrent  disease,  espe- 
cially tuberculosis.  S.  Finkelstein 
(These  de  Paris,  1900). 

Addison's  disease  in  children.  Be- 
fore puberty,  i.e.,  under  13  years,  it 
presents  considerable  differences  from 
that  above  this  age,  and  is  extremely 
rare.  Analysis  of  25  cases,  including 
a  personal  one.  As  to  relative  fre- 
quency, Monti  found  among  200  cases 
6  in  children  below  13,  while  Green- 
how  in  330  found  it  four  times;  in 
other  words,  1  to  62. 

Etiology. — The  main  etiological  factor 
is  tuberculosis,  though  the  patient  of 
Anglade  and  Jaciuin  showed  no  such 
lesion  in  the  adrenal  glands,  although 
extensive  tuberculosis  in  the  lungs 
and  spinal  cord  was  present.  Age: 
Twelve  cases  occurred  between  the 
ages  of  10  and  13  years,  4  cases 
between  5  and  10,  while  9  occurred 
below  the  age  of  5.  The  youngest 
case  on  record  is  that  of  Belyayeff,  of 
a  child  7  days  old.  Contrary  to  what 
textbooks  state,  that  the  disease  oc- 
curs far  more  frequently  in  boys  than 
girls,  the  occurrence  in  males  and 
females  is  about  equal. 

Family  History. — Tuberculosis  occur- 
red as  a  family  taint  in  4  cases;  in 
one  instance  a  rheumatic  history;  in 
one  instance  the  mother  and  four 
children  had  had  the  disease. 

Previous  History. — In  13  cases  in 
which  this  was  obtained  there  was 
tuberculosis  of  other  organs  in  3, 
measles  in  2,  scarlet  fever  in  2,  ton- 
sillitis and  chorea  in  1.  Felberbaum 
and  Fruchthandler  (N.  Y.  Med.  Jour., 
Aug.  10,  1907). 

Hypoglycemia  should  be  included 
among  the  symptoms  of  Addison's 
disease,  as  a  corollary  to  the  arterial 
subtension.  Bernstein  (Berl.  klin. 
Woch.,  Oct.  2,  1911). 

PATHOGENESIS.  —  The  patho- 
genesis of  Addison's  disease  cannot 
be  explained  except  by  referring  to 


ADDISON'S    DISEASE    (LANGLOIS). 


363 


the  data  of  physiolog-y,  and,  while 
Addison  was  deserving-  of  higli  credit 
for  pointing-  out  the  relation  of  the 
bronzed  disease  to  changes  in  the 
adrenals,  the  pathogenesis  none  the 
less  remained  obscure  because  the 
functions  themselves  of  the  adrenals 
were  still  unknown. 

Two  important  theories  have  been 
advanced,  which,  moreover,  do  not 
refer  exclusively  to  lesions  of  the 
adrenals,  but  to  which  recourse  is 
also  had  to  explain  the  morbid  syn- 
dromes related  to  lesions  of  all  duct- 
less glands,  including  the  thyroid 
gland,  the  pancreas,  etc.  These  are : 
1.  The  nervous  theory,  which  at- 
tempts to  explain  all  the  phenomena 
by  an  action  of  the  nervous  system 
through  its  adrenal  connections.  2. 
The  glandular  theory,  which  attrib- 
utes the  disturbances  to  functional 
alterations  in  the  adrenals. 

Ncrz'ous  TJicory.  —  The  nervous 
theory  had  already  been  clearly  stated 
in  Addison's  second  paper,  which 
pointed  out  the  close  relations  exist- 
ing between  the  solar  plexus,  with  the 
semilunar  ganglia,  and  the  adrenals. 
In  France,  Jaccoud  became  a  strong 
partisan  and  defender  of  this  theory. 
After  him  and  after  Addison,  Haber- 
shon,  Barlow,  Schmidt,  ]\Iattei,  and 
Alartineau  attributed  the  nervous 
disturbances  observed  to  lesions  of 
the  solar  plexus  and  semilunar  gan- 
glia. Following  Jaccoud,  this  view  is 
still  held  by  Greenhow,  Jurgens,  von 
Kahlden,  Lancereaux,  Raymond,  and 
Brault.  These  authors  offer  as  argu- 
ments, on  the  one  hand,  changes  in 
the  adrenals  in  cases  where  during 
life  the  subject  had  exhibited  none  of 
the  symptoms  referable  to  Addison's 
disease  and,  on  the  other  hand,  the 
normal   condition   of  the   adrenals   in 


individuals    declared    to    have    Addi- 
son's disease  before  the  autopsy. 

Jaccoud  supported  the  theory  on 
the  basis  of  three  orders  of  facts : 
the  symptoms  observed,  the  lesions 
found  post  mortem,  and  the  structure 
of  the  adrenal  glands.  Among  the 
symptoms  observed,  leaving  the  mel- 
anodermia  out  of  consideration  at 
once,  the  nervous  disturbances  are  of 
two  kinds :  increasing  asthenia  and 
the  gastric  or  nervous  manifestations. 
Prof.  Jaccoud,  after  referring  to  these 
symptoms,  adds:  'Tf  we  now  bear  in 
mind  that  in  the  uncomplicated  cases 
these  symptoms  show  progressive 
development  in  the  absence  of  any 
important  visceral  lesion,  without 
anemia,  without  albuminuria,  without 
hemorrhage,  and  without  diarrhea, 
they  will  without  doubt  appear  to  us 
as  the  direct  and  immediate  result  of 
a  disturbance  of  the  nervous  S3^stem." 
\\&  shall  see  later  that  these  asthenic 
phenomena  cannot  be  brought  forth 
as  arguments  in  favor  of  the  nervous 
theory,  and  that  the  capsular  theory, 
as  conceived  by  Abelous  and  Lan- 
glois,  itself  finds  strong  support  in 
the  asthenia  of  Addison's  disease,  de- 
scribed by  Jaccoud. 

The  autopsy  in  a  case  of  Addison's 
disease  in  a  child  of  10  years  showed 
tubercular  infiltration  of  the  lungs 
and  enlargement  of  the  bronchial 
glands.  The  suprarenal  capsules  were 
congested,  but  macroscopically  they 
presented  no  lesions.  A  microscopic 
examination  revealed  no  change  in 
the  histological  structure.  The  cap- 
sule was  of  normal  thickness,  and  the 
gland,  as  a  whole,  was  not  enlarged. 
The  nuclei  of  the  cells  were  distinct 
and  there  was  no  fattj^  degeneration. 
The  semilunar  plexus  was  somewhat 
altered  and  congested.  The  mesen- 
teric glands  were  large,  but  not  case- 
ous. Upon  examination  the  Bacillus 
tuberculosis  was  absent.    Richon  (Arch. 


364 


ADDISON'S    DISEASE    (LANGLOIS). 


de    med.    des    enfants,    tome    vi,    No. 
6,  p.  350,   1903). 

In  every  case  of  true  Addison's  dis- 
ease there  is  a  gray  degeneration  of 
the    nerve-fibers    of    the    splanchnics. 
This  may  be  either  protopathic,  when 
one  finds  simple  atrophy  of  the  ad- 
renals   without    other    inflammatory 
appearances  in  these  or  other  organs, 
or    (more   commonly)    deuteropathic, 
in  consequence  of  primary  disease  of 
the  adrenals   or  pancreas.     Withing- 
ton  (Med.  News,  Sept.  24,  1904). 
The   attacks    of   vomiting-   and    the 
epigastric  and  lumbar  pains  are,  in- 
deed, in  favor  of  nervous  lesions,  and 
it  can  readily  be  understood  how  the 
close    proximity    of    the    sympathetic 
nervous   structures   may    explain   the 
motor   and   sensory   disturbances   ob- 
served   in    cases   of   bronzed    disease. 
As  for  the  structure  of  the  adrenals, 
it  does  not  permit  of  our  forming  any 
definite  opinion. 

While  it  is  quite  true  that  these 
glands  receive  a  large  number  of 
nerve-fibers  from  the  sympathetic, 
as  shown  by  the  researches  of  Nagel, 
Bergmann,  Kolliker,  and  Henle,  there 
exist  in  the  cortical  layer  ganglionic 
cells  which  may  constitute  reflex 
centers  (Moers,  Joesten,  Holm)  ; 
and  while  it  is  true  that  excitation  of 
the  adrenals  tends  to  inhibit  the  in- 
testinal movements  (Jacob),  yet  the 
role  of  the  adrenal  bodies  cannot  be 
denied,  even  on  the  ground  of  their 
texture  alone.  The  main  argument 
against  the  pathogenetic  role  of  the 
adrenals  is  based  on  the  following 
double  series  of  observed  facts :  Mel- 
anodermia  may  exist  without  lesions 
of  the  adrenals;  marked  lesions  of 
the  adrenals  may  exist  without 
melanodermia. 

Glandular  Theory. — The  researches 
of  Brown-Sequard,  which  followed 
the    monograph    of    Addison    at    an 


interval  of  but  a  few  months,  were 
steeped  in  the  idea  which  then  pre- 
vailed as  to  the  "predominance  of 
melanodermic  disturbances  in  the 
bronzed  disease."  Furthermore,  while 
unable  to  observe  pigmentation  of  the 
skin  in  animals  deprived  of  their 
adrenals,  he  pointed  out  the  presence 
of  numerous  pigmentary  granulations 
in  the  blood.  The  most  prominent 
result  of  his  researches,  however,  lay 
in  the  discovery  of  the  functional 
importance  of  the  adrenals,  of  which 
the  role  had  until  then  escaped  physi- 
ologists. "Death  resulting  from 
changes  in  these  organs,"  wrote  this 
author,  "is  preceded  by  a  gradually 
developing  weakness,  going  on  to 
paralysis  of  the  posterior  extremities, 
then  of  the  anterior,  and  finally  of 
the  respiratory  muscles.  Among  the 
disorders  noted  may  also  be  men- 
tioned anorexia,  failure  of  digestion, 
rather  frequently  delirium,  epilepti- 
form disturbances,  and  a  gradual 
lowering  of  the  temperature."  Brown- 
Sequard  concluded  that  destruction 
of  the  adrenals  was  followed  by  ac- 
cumulation in  the  blood  of  a  toxic 
substance  ha^dng  the  property  of 
becoming  transformed  into  pigment. 
Since  1855  the  investigations  on  the 
adrenals  have  been  numerous.  The 
conclusions  of  Brown-Sequard  have 
been  vigorously  attacked.  Philip- 
peaux,  Gratiolet,  Harley,  Berutti,  and 
Martin-Magron  combated  the  vital 
role  of  the  adrenals,  asserting,  con- 
trary to  the  belief  of  Brown-Sequard, 
that  destruction  of  these  organs  did 
not  necessarily  result  in  death. 

Tizzoni,  in  numerous  researches 
carried  out  between  the  years  1884 
and  1889,  likewise  recognizes  the  pos- 
sibility of  survival  after  destruction 
of  both  adrenals ;  but  he  points  out  at 


ADDISON'S    DISEASE    (LANGLOIS). 


365 


the  same  time  the  possibility  of  regen- 
eration of  these  organs  when  not 
totally  destroyed;  finally  he  referred 
to  medullary  disorders  succeeding 
upon  destruction  of  one  adrenal. 

Stirling  showed  that  in  a  certain 
number  of  cases  survival  after  de- 
struction of  both  adrenals  is  explained 
by  the  presence  of  accessory  adrenals. 
Alezais  and  Arnaud  ascribed  the  fatal 
ending  to  ascending  degeneration 
reaching  the  cord  by  way  of  the 
splanchnics. 

Clinical  and  autopsy  findings  in 
3  cases:  The  morbid  changes  in 
the  suprarenals  were  accompanied  by 
corresponding  changes  in  the  other 
glands  with  an  internal  secretion,  the 
thyroid,  hypophysis,  and  spleen — all 
of  these  were  hypertrophied,  with 
evidence  of  hyperfunctioning.  The 
writer  does  not  regard  Addison's  dis- 
ease as  due  to  a  single  gland,  but  to 
several  participating  in  the  process. 
The  first  symptom  in  one  patient  was 
tremor  of  the  arms,  probably  the  re- 
sult of  professional  exposure  to  elec- 
tric currents,  the  man's  work  being 
done  under  an  electric  light  of  be- 
tween 15,000  and  20,000  candlepower. 
The  effect  of  the  Roentgen  rays  on 
glandular  organs  suggests  that  the 
light  here  may  have  affected  the  cer- 
vical sympathetic,  the  thyroid,  and  the 
hypophysis.  Later  the  process  seems 
to  have  extended  to  the  abdominal 
sympathetic  and  suprarenals.  In  an- 
other case  atrophy  of  the  ovaries  fol- 
lowed a  pregnancy  with  premature 
menopause.  Calcareous  degeneration 
of  the  thyroid  followed,  with  tuber- 
culous infection  later  and  fulminating 
suprarenal  symptoms.  The  diseased 
suprarenals  could  not  obtain  help 
from  the  ovaries  and  thyroid,  and 
there  was  merely  slight  hyperfunc- 
tioning of  the  hypophysis  as  a  de- 
fensive reaction.  In  the  3  cases 
patients  in  the  last  stages  of  Addi- 
son's disease  recovered  their  energy 
and  the  bronzing  subsided  under  thy- 
roid treatment.     The  thyroid  was  al- 


ready modified  and  was  inadequate  to 
supplant  the  diseased  suprarenals,  but 
it  only  required  slight  additional  aid 
from  without  to  be  able  to  counteract 
temporarily  the  destructive  process  in 
the    suprarenals.     The    disease,    the 
course,    the    outcome,    the    histologic 
findings,  the  research  in  the  experi- 
mental field,  all  sustain  the  assump- 
tion that  Addison's  disease,  in  its  com- 
plete form,  is   a  general  affection  of 
the  entire  great  sympathetic  system. 
Leonardi      (Policlinico,     Aug.,    1909; 
Jour.     Amer.     Med.    Assoc,     Oct.    2, 
1909). 
In     1891,    Abelous    and     Langlois 
published  their  first  researches  on  the 
functions    of    the    adrenals    in    frogs; 
these   were    followed   by   a   series    of 
papers  on  the  functions  of  the  glands 
in  other  animals.     They  showed  that, 
in    all    animals    subjected    to    double 
adrenalectomy,    death    promptly    and 
inevitably  occurs,  but  that  a  portion 
of  an  organ  if  left  behind  is  sufficient 
to   cause   survival.      Muscular   weak- 
ness  and   asthenia   are   all   the   more 
intense  if  the  animal  be  forced  to  per- 
form   muscular    movements,    whence 
their    first    conclusion    "that    the    ad- 
renals  possess   the   function   of   neu- 
tralizing   or    destroying    toxic    sub- 
stances     evolved     during     muscular 
labor."     This   conception  of  the  role 
of  the  adrenals  explains  a  portion  of 
the  symptoms  observed  in  Addison's 
disease,    including    the    most    charac- 
teristic symptoms :    asthenia  and  the 
disastrous  effects  of  fatigue. 

The  discovery  of  the  vasoconstrict- 
ing  action  of  suprarenal  extract  by 
Oliver  and  Schafer,  on  the  one  hand, 
and  Cybulski,  on  the  other,  that  of 
the  presence  of  the  active  substance  in 
the  blood  of  the  capsular  vein  (Cy- 
bulski and  Langlois),  that  of  the 
rapid  destruction  of  this  substance  in 
the  organism  (Langlois),  and  finally 


)66 


ADDISON'S    DISEASE    (LANGLOIS). 


the  isolation  of  adrenalin  by  Taka- 
mine  also  threw  new  light  on  the 
symptoms  observed.  The  lowered 
vascular  tension  and  the  cerebral 
disorders  can  henceforth  be  inter- 
preted as  resulting-  from  diminution 
of  the  tonic  influence  of  the  adrenals. 
The  syndrome  of  adrenal  insufficiency 
in  its  entirety  can  henceforth  be  ex- 
plained through  the  data  of  experi- 
mental physiology. 

Study  of  the  nitrogen  and  sulphur 
metabolism  in  a  patient  who  had  Ad- 
dison's disease  and  who  was  on  a 
purin-free  diet.  The  desamidating 
capacity  of  the  patient  (capacity  to 
reduce  amid  nitrogen)  and  his  capac- 
ity to  transform  the  sulphur  of  the 
cystin  group  into  sulphuric  acid  were 
absolutely  comparable  to  that  of  nor- 
mal individuals.  A  considerable  de- 
gree of  acidosis  was  observed,  which 
is  not  accounted  for  by  any  factor 
which  was  found  in  this  examination. 
The  endogenous  metabolism  of  the 
patient,  as  represented  by  the  kreati- 
nin  and  uric  acid  outputs,  was  below 
that  of  normal  subjects.  Wolf  and 
Thacher  (Arch,  of  Int.  Med.,  June, 
1909). 

The  writer,  who  had  previously  ob- 
served a  striking  hypoglycemia  after 
removal  of  the  adrenals,  now  reports 
the  effect  upon  the  glycogen  content 
of  the  liver  and  muscles  of  the  same 
procedure.  Seven  dogs  were  killed 
at  intervals  of  four  and  one-half  to 
eight  hours  after  removal  of  the  ad- 
renals. At  this  time  all  showed  great 
muscular  weakness.  Their  livers  con- 
tained an  average  of  0.722  per  cent, 
glycogen.  If  one  animal  be  excluded, 
the  average  of  the  other  six  was  0.222 
per  cent.  Schondorff  found  18.69  to 
1 .2>  per  cent,  of  glycogen  in  the  livers 
of  normal  dogs  on  a  similar  diet.  The 
muscle  content  of  glycogen  was  0.653 
per  cent.,  compared  with  Schondorfif's 
average  of  4  per  cent.  In  three  dogs 
dying  spontaneously  after  operation, 
the  livers  contained  no  glycogen  what- 
ever, the  muscles  an  average  of  0.187 
per  cent.    The  lack  of  glycogen  is  the 


cause  of  the  hypoglycemia.  The  mus- 
cular weakness  is,  in  all  probability, 
due  to  lack  of  sufficient  sugar  and 
sugar-producing  material,  for  muscle 
glycogen  is  well  known  to  be  far  less 
readily  available  for  the  body  than  is 
the  liver  glycogen.  Porges  (Zeit.  f. 
klin.  med.,  Bd.  Ixx,  S.  243,  1910). 

Adrenalin  glycosuria  is  due  to  the 
conversion  of  liver  glycogen  into  su- 
gar. In  animals  rendered  glycogen- 
free  by  starvation  and  strychnine  poi- 
soning, adrenalin  injections  cause  a 
new  formation  of  glycogen  and  sugar. 
Pollack  (Arch.  f.  exper.  Path.  u.  Phar- 
mak.,  Bd.  Ixi,  S.  149,  1909). 

Even  the  insufficiency  or  complete 
failure  of  adrenal  opotherapy  finds 
its  explanation  in  the  instability  of 
suprarenal  extracts.  (We  retain  this 
vague  term  to  convey  the  fact  that 
adrenalin  is  but  one  of  the  principles 
now  isolated  which  are  elaborated  by 
the  adrenals). 

But  while  physiology  can  explain 
and  experimentally  reproduce  most 
of  the  symptoms  of  Addison's  disease 
— those  which  Bernard  and  Sergent 
classify  in  the  syndrome  of  pure 
adrenal  insufficiency — she  has  shown 
herself  entirely  powerless  to  repro- 
duce and  explain  the  pigmentation 
which  is  so  characteristic  of  this 
affection. 

Excepting  in  one  observation  by 
Boinet,  no  experimenter  has  been 
able  to  produce  pigmentation  experi- 
mentally, either  by  destroying  the 
adrenals  or  by  setting  up  local  irrita- 
tion. 

Following  Loeper  we  shall  refer 
into  four  groups  the  theories  which 
have  been  advanced  to  explain  mel- 
anodermia :  adrenal  origin,  cachectic 
origin,  nervous  origin,  and  mixed 
glandular  and  sympathetic  origin. 

A.  Adrenal  Origin. — The  elabora- 
tion of  a  pigment  by  the  secretion  of 


ADDISON'S    DISEASE    (LANGLOIS). 


367 


the  adrenals,  thought  of  by  Brown- 
Sequard  and  Pfandler,  and  which 
would  be  caused  by  lesions  of  the 
org-an  itself,  is  not  supported  by  any 
evidence  of  value.  The  hemolytic 
function  of  the  g-land  and  the  accumu- 
lation in  the  blood  of  pigment  derived 
from  hemoglobin  when  the  glandular 
function  is  weakened  arc  likewise  too 
hypothetical. 

B.  Cachectic  Origin  (Gubler,  Teis- 
sier, Debove). — It  is  certainly  true 
that  any  cachexia  may  provoke,  along 
with  general  nutritional  disorders, 
pigmentary  phenomena.  But  the 
bronzed  disease  is  frequently  mani- 
fest previous  to  the  establishment  of 
cachexia,  and  presenting  features 
which  give  it  a  specific  character 
which  does  not  bear  well  with  the 
general  processes  of  the  cachexia. 

C.  Nervous  Origin. — The  intimate 
connections  existing  between  the 
adrenals  and  the  sympathetic  system 
are  such  as  to  warrant  a  belief  in 
functional  changes  in  this  system 
during  Addison's  disease.  Addison 
had  already  thought  of  the  possible 
role  of  the  nervous  system.  Jaccoud, 
Lancereaux,  and  Raymond  defended 
this. theory. 

The  clinical  observations  of  Sem- 
mola  and  of  Brault,  who  noted  mel- 
anoderma in  conjunction  with  sim- 
ple compression  of  the  semilunar 
ganglia  and  solar  plexus,  and  the 
cases  of  Addison's  disease  with 
lesions  of  but  one  adrenal  (Green- 
how)  are  cited  as  favoring  the  view 
of  nervous  origin.  Irritation  of  the 
sympathetic  would  presumably  bring 
about  an  overproduction  of  pigments, 
either  in  the  blood  itself  (von  Kahl- 
den,  Nothnagel),  in  the  chromoblasts 
(Raymond)  or  in  the  cells  of  the 
epidermis  (Behier,  Chatelin). 


D.  Mixed  Origin. — Attractive  as  the 
nervous  theory  may  be,  it  does  not 
suffice  in  all  cases,  and  especially  is 
in  complete  disagreement  with  ex- 
perimental facts,  since  all  excitations 
of  the  sympathetic,  whether  extra-  or 
intra-  capsular,  have  proven  without 
efifect  in  producing  melanodermia.  A 
number  of  physicians  are  at  present 
adopting  the  opinion  of  Loeper,  that 
melanodermia  is  the  result  of  changes 
both  in  the  adrenals  and  the  nervous 
network  surrounding  them.  Accord- 
ing to  Loeper,  the  adrenal  secretion  is 
the  normal  and  necessary  exciting 
agent  of  the  nervous  system  in  its 
function  of  regulating  pigmentation. 
Sajous  (1903)  and  Laignel-Lavastine 
hold  an  opposite  view :  the  sympa- 
thetic is  not  the  regulator  of  pigmen- 
togenesis,  but  of  the  adrenal  gland 
itself,  on  which  the  formation  of 
pigment  .depends. 

Addison's  disease  is  not  infre- 
quentlj^  accompanied  by  enlaro^ement 
of  the  lymphatic  glands,  and  hyper- 
plasia of  the  spleen  and  thymus.  The 
writer  saw,  in  one  year,  three  cases 
of  this  disease  with  very  marked 
status  lymphaticus.  Examinations  of 
the  autopsy  records  of  the  Berne  and 
Basle  Pathological  Institutes  showed 
that  the  latter  condition  frequently  is 
associated  with  Addison's  disease. 
The  hyperplasia  of  the  lymphatic  sys- 
tem in  these  cases  must  be  due  to  Ad- 
dison's disease.  By  special  stains  he 
found  that  the  chromaffin  cells  of  the 
adrenal  gland,  including  the  para- 
ganglion,  were  greatly  reduced.  The 
change  or  the  defective  anlage  of  the 
chromaffin  cells  is  the  common  cause 
for  Addison's  disease  and  of  status 
lymphaticus.  Hedinger  (Zeit.  f.  Pa- 
thol.; Charlotte  Med.  Jour.,  Aug., 
1908).. 

Two  cases,  pronounced  hypoplasia 
of  the  chromaffin  system,  accom- 
panied the  typical  Addison's  disease, 
while  the  lymph-glands  were  enlarged. 


368 


ADDISON'S    DISEASE    (LANGLOIS). 


V.  Werdt  (Berl.  klin.  Woch.,  Dec.  26, 
1910). 

Case  of  chronic  Addison's  disease 
in  a  youth  with  the  thymolymphatic 
temperament.  The  suprarenals  had 
been  totally  destroyed  by  a  primary 
tuberculous  process,  as  also  in  a  simi- 
lar case  in  a  man  of  41  with  the  status 
lymphaticus.  Analysis  of  these  cases 
and  of  similar  ones  in  the  literature 
seems  to  demonstrate  a  mutual  stim- 
ulating action  between  the  thyroid 
and  the  suprarenals  and  between  the 
thyroid  and  the  thymus,  while  there 
is  mutual  inhibiting  action  between 
the  suprarenals  and  the  thymus. 
Kahn  (Virchow's  Archiv,  June,  1910). 

DIAGNOSIS.— The  various  symp- 
toms encountered  in  Addison's  dis- 
ease may  be  divided  into  two  groups: 

A.  Symptoms  of  adrenal  insufficiency. 
Cardiovascular  disturbances ; — 

Lowered      arterial      tension.        Tachy- 
cardia. 

White  line  on  abdomen. 

Cerebral  anemia.     Syncope. 
Disturbances   of   metabolism  : — 

Lowered  temperature  and  sensation  of 
cold. 

Progressive  asthenia.     Wasting.     Pros- 
tration. 

Encephalopathy    and    various    nervous 
disorders.      Vomiting   and   diarrhea. 

B.  Symptoms  of  irritation  of  the  adrenal 
sympathetic. 

Melanodermia. 
Radiating  pains. 
Vomiting  and  diarrhea. 

Where  the  Addisonian  syndrome 
is  complete  and  the  course  rapid,  the 
diagnosis  is  easily  made.  It  becomes 
more  difficult  when  melanodermia  is 
absent  or  doubtful.  A  study  of  the 
resistance  to  fatigue,  either  by  means 
of  the  ergograph  or  by  simply  caus- 
ing the  patient  to  perform  a  definite 
piece  of  work,  combined  with  the  use 
of  the  sphygmomanometer,  may  be 
of  value  in  facilitating  diagnosis,  but 
very  often  in  the  hospital,  in  cachectic 


tuberculous  subjects,  the  involvement 
of  the  adrenals  is  not  discovered  till 
the  autopsy. 

In  fact,  the  question  of  diagnosis  is 
generally  raised  when  it  becomes 
necessary  to  attribute  the  melano- 
dermic  patches  to  Addison's  disease 
or,  on  the  other  hand,  to  some 
other  affection  producing  pigmentary 
changes,  such  as  the  pigmentation  of 
cachectic  tuberculous  cases,  pigmen- 
tation of  hepatic  origin,  the  melano- 
dermias  of  malaria,  arsenic  poisoning, 
lead  poisoning,  and  phthiriasis. 

The  most  common  fallacy  is  to  mis- 
take Addison's  disease  for  pernicious 
anemia;  the  peculiar  lemon  tint  of  the 
skin  in  the  latter  condition,  however, 
is  different  from  that  of  the  charac- 
teristic case  of  Addison's  disease;  but 
in  slight  cases  confusion  often  arises. 
Fortunately,  modern  means  of  exam- 
ination of  the  blood,  which  in  Addi- 
son's disease  is  but  little  abnormal, 
enable  the  recognition  of  the  marked 
blood  characteristics  of  pernicious 
anemia.  The  writer,  however,  cau- 
.  tions  against  being  content  with 
negativing  a  diagnosis  of  pernicious 
anemia  because  a  single  blood  exam- 
ination fails  to  show  characteristic 
changes.  The  blood  in  pernicious 
anemia  varies  from  day  to  day  and 
from  hour  to  hour.  Another  pos.sible 
source  of  confusion  is  the  discolora- 
tion consequent  on  prolonged  admin- 
istration of  arsenic.  By  inquiry  of 
many  persons  of  considerable  experi- 
ence in  arsenical  poisoning  the 
writer  finds  that  the  occurrence  of 
pigmentation  in  the  mouth  is  in  favor 
of  the  case  being  Addison's  disease. 
In  malignant  disease  the  wasting  is 
apt  to  be  much  more  marked,  and 
local  evidence  of  malignancy  can 
usually  be  found.  Other  conditions 
sometimes  confounded  with  Addison's 
disease,  but  which  ought  to  be  easily 
distinguishable,  are  the  filthy,  dirty 
patients,  infested  with  lice,  sometimes 
seen  in  hospital  out-patient  depart- 
ments; phthisical  and  syphilitic  pig- 


ADDISON'S    DISEASE    (LANGLOIS).    , 


369 


mentation;    Hanot's    cirrhosis   of   the 
liver,  and  bronzed  diabetes. 

Any  condition  that  destroys  the 
functional  activity  of  the  medullary 
part  of  the  suprarenals  may  cause  Ad- 
dison's disease,  by  far  the  most  com- 
mon being  tuberculous  degeneration. 
Calmette's  reaction  helps  in  this  mat- 
ter. The  comparative  frequency  of 
malignant  disease  as  a  cause,  the  au- 
thor considers  due  to  the  necessity  of 
having  both  suprarenals  affected,  and, 
perhaps,  to  the  fact  that  in  malignant 
disease  death  will  be  occasioned  be- 
fore the  evolution  of  characteristic 
phenomena.  The  proportion  of  cases 
in  which  clinically  characteristic  Ad- 
dison's disease  has  failed  to  show  dis- 
ease of  the  suprarenals  is  so  small, 
about  12  per  cent.,  as  to  be  within 
the  margin  of  allowable  error  due  to 
erroneous  diagnosis,  inefficient  post- 
mortem examination,  or  the  possibil- 
ity of  functional  disturbance  of  the 
suprarenals.  Further,  other  glands, 
e.g.,- the  internal  carotid  and  the  coc- 
cygeal, have  cells  functionally  resem- 
bling those  of  the  suprarenals,  and  it  is 
conceivable  that  very  rarely  disease 
of  these  glands  may  cause  Addison's 
disease  and  lead  to  death  before  the 
suprarenals  are  affected.  On  the  other 
hand,  when  the  suprarenals  have  been 
found  to  be  diseased,  and  yet  no  Ad- 
dison's disease  has  been  present,  it 
may  be  that  the  vicarious  activity  of 
these  other  glands  may  have  formed 
sufficient  internal  secretion  to  prevent 
the  patient  having  Addison's  disease. 
W.  H.  White  (Clinical  Journal,  Mar. 
18,  1908). 

The  melanodermia  of  phthisical 
patients  is  all  the  more  likely  to  lead 
one  astray  because  of  the  fact  that 
the  cases  of  Addison's  disease  are 
almost  all  tuberculous.  For  some 
authors,  moreover,  the  majority  of 
melanodermic  tuberculous  cases  are 
cases  of  Addison's  disease  in  which 
the  adrenal  changes  are  just  begin- 
ning-, not  yet  showing  the  signs  of 
glandular    insufficiency,    but    having 


pericapsular  lesions  which  cause  a 
precocious  melanodermia.  In  pig- 
mented tulDcrculous  subjects  without 
Addison's  disease  the  pigmentation  is 
said  to  be  of  a  lighter  grade  and 
especially  the  mucous  membranes  to 
be  unaffected. 

Three  cases  of  tuberculosis  of  the 
suprarenals  in  which  there  was  no 
pigmentation.  The  diagnosis  was 
made  in  two  from  the  remarkable'^ 
weakness  of  the  patients  in  strong 
contrast  to  their  well-nourished  as- 
pect. Another  sign  is  the  low  blood- 
pressure,  not  to  be  explained  to  any 
disturbances  on  the  part  of  the  heart. 
Gastrointestinal  disturbances  without 
traceable  cause  are  further  corrobora- 
tive testimony.  These  findings  differ- 
entiate Addison's  disease  even  with- 
out pigmentation  of  skin  or  mucosae. 
Stursberg  (Miinch.  med.  Woch.,  Bd. 
liv,  Nu.  16,  1907). 

Cases  of  liver  cirrhosis  and  even  a 
few  incipient  hepatic  cases  without 
appreciable  change  in  the  size  of  the 
liver  present  either  disseminated  he- 
patic patches  of  discoloration  or  a 
diffuse  melanodermia  of  the  same 
color  as  in  Addison's  disease.  Here 
again  the  mucosae  are  but  slightly  or 
not  at  all  involved,  and  the  hepatic 
disorders  place  one  on  the  right  track. 

Arsenical  pigmentation  is  a  rare 
occurrence ;  the  same  is  true  of  sat- 
urnine pigmentation.  In  the  latter 
the  blue  line  on  the  gums  is  generalh^ 
sufficient  to  permit  diagnosis.  In 
pigmentation  due  to  arsenic,  the  color 
is  more  slaty  in  hue,  and  a  dark  mot- 
tling is  also  present,  which  is  rather 
characteristic.  Finally  the  signs  of 
arsenical  intoxication,  together  with 
the  absence  of  those  of  adrenal  in- 
sufficiency, serve  to  establish  the 
diagnosis. 

In  malarial  subjects  the  pigmenta- 
tion again  does  not  involve  the  mu- 


1—24 


370 


ADDISON'S    DISEASE    (LANGLOIS). 


cous  membranes,  it  Is  more  diffuse 
and  uniform,  and  the  special  indica- 
tions of  malaria  are  present. 

The  melanodermias  of  phthiriasic 
origin  (pediculosis)  seen  among- vaga- 
bonds in  a  state  of  physiological  de- 
bility, and  who  are  bearers  of  para- 
sites, are  accompanied  by  itching  and 
cutaneous  excoriations.  The  causa- 
tive agent  may  be  discovered. 

On  the  whole,  it  should  be  borne  in 
mind  that  the  melanodermia  of  Addi- 
son's disease  differs  from  other  forms 
of  pigmentation  in  that  it  shows 
marked  preference  for  mucous  mem- 
branes, although  this  characteristic 
should  not  be  put  down  as  absolutely 
distinctive. 

Early  diagnosis  is  all  important, 
though  often  very  difficult.  The  dis- 
ease gives  rise  to  definite  signs  and 
symptoms,  and  usually  to  marked  le- 
sions of  the  medulla  of  the  suprarenal 
gland.  The  solar  plexus  is  frequently 
diseased,  owing  to  the  influence  of 
the  secretion  of  the  gland  in  stimulat- 
ing the  sympathetic  system.  Pathog- 
nomonic signs  are  asthenia,  pigmen- 
tation, voiniting,  and  attacks  of  faint- 
ness.  If  these  symptoms  are  well 
marked  the  diagnosis  is  not  difiicult, 
but  when  they  have  become  evident 
the  chances  of  successful  treatment 
are  not  good.  Grunbaum  (Practi- 
tioner, Aug.,  1907). 

Two  personal  cases  which  empha- 
size the  resemblance  existing  between 
Addison's  disease  and  tabes  dorsalis. 
Both  patients  presented  an  almost 
identical  pigmentation,  and  both  had 
muscular  atrophy.  One  was  a  typical 
case  of  Addison's  disease,  while  the 
presence  of  tabes  was  undoubted  in 
the  other.  It  is  not  necessary  to  as- 
sume a  combination  of  tabes  dorsalis 
with  Addison's  disease,  however,  since 
other  symptoms  of  the  last-named 
affection  were  lacking.  The  pigmen- 
tation should  rather  be  referred  to 
tabetic  changes  of  the  nervous  sys- 
tem.     Possibly    the    pigmentation   in 


Addison's  disease  is  likewise  the  ex- 
pression of  disease  on  the  part  of  the 
nervous  system.  In  this  particular 
instance  atrophy  of  the  shoulder  mus- 
cles was  said  to  have  been  present 
ever  since  birth,  and  atrophy  of  the 
thigh  muscles  was  claimed  to  have 
followed  later,  in  connection  with 
traumatism.  Wagner  (Berl.  klin. 
Woch.,  Nu.  IS,  1908). 

TREATMENT.  — Addison's  dis- 
ease of  pure  type  or  manifested  in  the 
syndrome  of  adrenal  insufficiency 
without  melanodermia  is  largely 
caused  by  tuberculosis  of  the  ad- 
renals. The  general  treatment  of 
tuberculosis,  or  rather  that  form  of 
treatment  which  is  in  vogue  in  a 
given  locality  at  the  time,  is  indi- 
cated. Syphilis  of  the  adrenals  is 
rarely  diagnosticated  during  life;  at 
the  autopsy  may  be  found  either  ex- 
tensive gummata,  a  miliary  syphilo- 
sis  or,  especially  in  the  young,  a 
sclerosis  resulting  in  atrophy  of  the 
gland.  In  doubtful  cases  the  effect 
of  specific  treatment  may  be  tried. 
Certain  cases  seem  to  have  been  bene- 
fited by  the  iodides,  with  or  without 
the  addition  of  mercury  (Schwytzer, 
A.  Andrews). 

Cases  of  bona  fide  acute  adrenitis 
with  or  without  hemorrhage,  which 
are  almost  always  frankly  infec- 
tious in  origin  (small-pox,  diph- 
theria, etc.),  generally  run  a  very 
rapid  course  and  do  not  possess  any 
special  line  of  treatment.  As  for  the 
morbid  growths — sarcoma,  epithe- 
lioma, carcinoma,  etc. — which  it  is 
almost  impossible  to  diagnosticate 
during  life,  unless  perhaps  it  be  when 
persistent  edema  is  noted  in  com- 
bination with  the  usual  syndrome, 
surgical  intervention  is  indicated, 
though  the  results  obtained  by  Israel, 
Mayo,    Kelly,    Lecenne,    and    Hart- 


ADDISON'S   DISEASE    (LANGLOIS). 


371 


mann  have  afforded  but  little  en- 
couragement. 

Physiological  data  naturally  led  to 
the  trial  of  adrenal  opotherapy.  This 
treatment  was  first  instituted  by 
Abelous,  Charrin,  and  Langlois  in  the 
form  of  a  glycerin  extract  of  the 
adrenals  of  guinea-pigs,  dogs,  and 
horses.  The  patients  were  in  such  a 
state  of  cachexia  that  no  results  were 
obtained,  but  in  two  less  advanced 
cases,  employing  injections  each  rep- 
resenting Gm.  0.10  of  the  dried  ex- 
tract, Langlois  obtained  better  results 
and  in  particular  a  notable  diminution 
of  the  asthenia. 

Since  that  time  numerous  trials  have 
been  made  and  the  treatment  mark- 
edly altered.  Among  the  methods 
that  have  been  tried  are:  1.  Hypo- 
dermic injections  of  the  extract.  2. 
Ingestion  of  fresh  or  dried  glandular 
substance.  3.  Injection  of  adrenalin 
solution.  4.  Grafting  of  adrenal 
tissue. 

1.  The  injections  of  extract  of  the 
suprarenals  were  early  abandoned 
because  of  the  great  pain  they  occa- 
sioned and  the  fact  that  they  failed  to 
give  satisfactory  results  in  a  large 
number  of  cases. 

2.  The  ingestion  of  fresh  or  dried 
gland  has  furnished  a  few  unhoped- 
for results,  together  with  numerous 
failures.  Beclere  and  Anderodias  re- 
port cases  of  cure,  or,  perhaps  better, 
disappearance  and  long-continued  ab- 
sence of  the  symptoms  of  adrenal 
insufficiency.  It  is  advised  to  use  the 
adrenals  of  calves  and  start  with 
doses  of  Gm.  1.5  to  2.0,  which  are 
gradually  increased  to  Gm.  6.0. 
Sajous  employs  the  dried  gland  (the 
glandulse  suprarenales  siccse  of  the 
U.  S.  P.).  The  dried  extract  may  be 
given  in  capsules  in  the  dose  of  Gm. 


0.25  to  0.35  daily  for  ten  successive 
days;  it  is  left  off  for  four  days,  then 
resumed  for  six  to  eight  days,  etc. 
Systematic  testing  with  the  sphygmo- 
manometer should  be  used  as  a  guide 
in  the  treatment.  Improvement  in 
the  arterial  tone  is  to  be  considered 
the  sign  of  efficiency  in  the  treatment, 
while  any  indication  of  hypertonicity 
demands  immediate  stoppage  of  the 
administration  of  adrenal. 

Adams's  paper  in  the  Practitioner  for 
October,  1903,  includes  an  analysis 
of  97  cases  treated  with  a  preparation 
of  the  suprarenal  glands.  Of  these,  7 
were  distinctly  made  worse  by  the 
treatment,  43  derived  no  benefit,  31 
showed  marked  improvement,  and  16 
were  cured.  The  methods  of  treat- 
ment in  these  cases  may  be  divided 
into  five  heads:  1.  Suprarenal  grafts. 
Three  patients  were  treated  by  this 
method  and  all  died.  2.  Nine  pa- 
tients were  treated  by  fresh  glands 
given-  by  the  mouth;  of  these,  1  be- 
came worse,  1  was  not  benefited,  6 
were  improved,  and  1  permanently  re- 
lieved. 3.  Eleven  patients  were 
treated  by  hj^podermic  and  intramus- 
cular injection.  One  became  worse, 
6  derived  no  benefit,  3  were  improved, 
and  1  permanently  benefited.  4. 
Sixty-one  cases  were  treated  with  the 
fluid  or  solid  extract  of  the  suprarenal 
gland  by  the  mouth.  Of  these,  2  were 
made  worse,  32  derived  no  benefit,  17 
were  markedl}-  improved,  and  10  were 
permanently  relieved.  5.  Fi^^e  pa- 
tients were  treated  by  mixed  meth- 
ods; 3  were  improved  and  2  cured. 

The  cases  most  likely  to  derive  bene- 
fit from  the  specific  treatment  are 
those  in  which  the  process  is  a  chronic 
sclerosis  and  in  which  the  other  or- 
gans are  fairly  sound.  D.  Symmers 
(Med.  News,  Sept.  10,  1904). 

Case  of  Addison's  disease  which  im- 
proved .remarkably  under  the  open-air 
treatment  and  the  simultaneous  admin- 
istration of  suprarenal  extract.  The 
patient,  a  man,  aged  36,  had  been  ill 
for   eighteen   months.     He    applied    for 


372 


ADDISON'S    DISEASE    (LAXGLOIS). 


treatment  early  in  November,  the 
weather  at  the  time  being  cold,  wet, 
and  stormy.  The  man  was  placed  on 
the  balcony  outside  the  hospital  ward 
and  stood  the  exposure  well.  The  su- 
prarenal extract  was  administered  in  5- 
grain  doses  three  times  daily.  All  the 
symptoms  disappeared  rapidly  and  the 
patient  was  discharged  as  cured  five 
and  one-half  months  after  the  begin- 
ning of  the  treatment.  Death  occurred 
suddenly  two  years  afterward,  due  to 
asthenia  and  failure  of  the  heart  action. 
Bramwell  (Brit.  Med.  Jour.,  Oct.  28, 
1905). 

Case  in  a  male,  aged  18,  which  fol- 
lowed a  very  rapid  course,  i.e.,  less  than 
four  months,  although  suprarenal  gland 
was  given  up  to  15  grains  thrice  daily. 
At  the  autopsy  chronic  adrenal  tuber- 
culosis was  evident,  with  secondary  in- 
flammation of  the  neighboring  SA-m- 
pathetic  plexuses.  Second  case  in  a 
female,  aged  32,  who  had  been  ill  two 
years.  Adrenal  gland  caused  so  much 
improvement  that  she  stood  pregnancy 
parturition  ■  easily,  and  bore  a  healthy 
child.  She  was  given  5  grains,  which 
were  rapidly  increased  to  20  grains 
thrice  daily.  If  she  vomited  the  ad- 
renal extract  for  a  few  days  her  symp- 
toms began  to  return.  A.  G.  Gullan 
(Lancet,  Aug.  19,  1905). 

Case  reported  in  a  boy  18  years  of 
age,  who  was  brought  to-  the  hospital 
in  a  fainting  condition.  He  was  gasp- 
ing for  breath  and  sank  exhausted  into 
a  chair.  A  walk  of  half  a  mile  pre- 
ceding his  admission  was  accomplished 
with  the  greatest  difficult}',  and  only 
after  repeated  rests.  The  pulse  was 
uncountable;  respiration  was  rapid. 
The  symptoms  had  existed  for  three 
months.  It  was  stated  by  the  mother 
of  the  patient  that  the  boy's  father  had 
died  of  the  same  disease  after  some 
years  of  illness.  The  skin  was  gen- 
erally pigmented,  with  well-marked 
patches  on  the  forehead.  The  patient 
only  complained  of  extreme  fatigue. 
After  a  few  days  extract  of  suprarenal 
was  administered  in  the  form  of  tab- 
lets, beginning  with  1  three  times  a 
day,  which  soon  increased  to  2  three 
times  a  day.     Under  the  treatment  im- 


provement was  rapid.  In  two  weeks 
there  was  a  gain  of  6  pounds  in  weight 
and  the  pulse  had  decreased  to  110,  and 
he  was  able  to  move  about  the  room 
with  less  difficulty.  The  pigmentation 
was  less  marked.  The  treatment  was 
continued  until  500  tablets  were  taken. 
The  patient  gained  56  pounds  in  weight, 
the  pigmentation  entirely  disappeared, 
and  he  was  able  to  resume  work  as  an 
active  farm  laborer.  R.  E.  Weigall 
(Austral.  Med.  Gaz.,  Oct.  20,  1905). 

The  writer  takes  the  blood-pressure 
at  least  three  times  in  all  suspected 
cases,  and  if  it  is  found  low  adminis- 
ters suprarenal  extract  bj'  the  mouth,  3 
grains  three  times  a  day,  for  three  days. 
If  there  is  a  rise  of  more  than  10  per 
cent,  in  the  pressure,  the  probability 
that  the  patient  suffers  from  adrenal 
insufficiency  approaches  a  certainty.  In 
regard  to  the  blood,  the  opsonic  index 
of-  the  serum  for  the  tubercle  bacillus 
may  be  taken,  as  tuberculosis  is  the 
commonest  cause  of  the  destruction  of 
the  capsule.  Griinbaum  (Practitioner, 
Aug.,  1907). 

Case  of  Addison's  disease  which  ex- 
hibited all  the  typical  symptoms  of  this 
affection.  When  the  patient  was  first 
seen  the  adynamia  was  so  marked  that 
an  unfavorable  prognosis  was  made. 
Owing  to  the  secretory  and  motor  in- 
sufficiency of  the  stomach,  gastric  la- 
vage with  salt  solution  was  practised. 
Nutrient  enemas  were  given  and  hy- 
drochloric acid,  but  nothing  else  in  the 
way  of  remedial  agents.  The  patient 
slowly  gained  in  strength  and  weight 
and  eventually  was  dismissed  in  a  very 
much  improved  condition.  The  skin 
pigmentation  also  lessened,  but  not  so 
much  but  that  a  military  surgeon  was 
able  to  diagnose  Addison's  disease  when 
the  applicant  was  examined  for  the 
service.  Since  1903  the  patient  had 
improved  steadily,  and  the  author  be- 
lieves that  the  man  may  be  considered 
as  cured.  In  another  instance,  to  which 
reference  is  made,  this  treatment  pro- 
duced similar  good  results.  The  im- 
portance of  gastric  lavage  is  empha- 
sized in  these  and  other  cases  for  the 
purpose  of  removing  from  the  gastro- 
intestinal   canal    toxins    which    it    may 


ADDISON'S   DISEASE    (LANGLOIS). 


373 


contain.     Grawitz    (Dent.    mcd.    Woch., 
July  4,  1907). 

Our  experience  with  Addison's  dis- 
ease justifies  the  belief  that  one-sixth 
of  the  cases  can  be  cured  by  the  timely 
and  persistent  use  of  suprarenal  ex- 
tract, while  a  considerable  larger  pro- 
portion, perhaps  25  per  cent,  more,  can 
be  substantially  benefited.  It  does  not 
appear  that  surgery  can  help  us  here, 
because  in  so  far  as  the  adrenals  are 
involved  it  is  the  loss  of  secretion,  as 
it  is  of  the  thyroid  in  myxedema,  which 
lies  at  the  bottom  of  the  syndrome.  G. 
W.  McCaskey  (Jour.  Indiana  State 
Med.  Assoc,  Jan.  15,  1908). 

Case  of  well-defined  Addison's  dis- 
ease in  which  the  extreme  languor, 
asthenia,  and  emaciation  indicated  a 
rapidly  fatal  outcome,  but  under  or- 
ganotherapy the  symptoms  subsided  and 
the  patient,  a  man  of  34,  has  been  in 
good  health  during  the  ten  j^ears  since. 
The  gland  substance  was  eaten  fresh 
and  a  glycerin  extract  was  injected  two 
or  three  times  a  week.  There  are  still 
traces  of  pigmentation,  confirming,  the 
writer  thinks,  the  assumption  of  the 
nervous  origin  of  this  symptom.  Be- 
clere  has  reported  a  similar  case  of  per- 
manent recovery  under  organotherapy. 
The  suprarenal  treatment  evidently  acts 
by  stimulating  to  hypertrophy  the  parts 
of  the  suprarenal  capsules  which  are 
still  intact,  thiis  i.isuring  adequate 
functioning.  The  writer  cites  5  other 
cases  that  have  been  reported  in  France 
with  marked  improvement  imder  or- 
ganotherapy- and  adds  3  from  his  own 
experience,  all  the  symptoms,  except 
the  pigmentation,  showing  great  benefit 
from  the  suprarenal  treatment.  E. 
Boinet  (Bull,  de  I'Acad.  de  Med.,  Oct. 
5,  1909). 

Series  of  120  cases  collected  from 
literature,  including  97  previously  col- 
lected by  E.  W.  Adams,  in  all  of  which 
adrenal  preparations  had  been  used  in 
some  form,  gave  the  following  results : 

1.  Cases  in  which  death  ran  be  as- 

cribed   to    grafting    or    adrenal 
preparations    8 

2.  Cases   in   which   the   benefit  was 

slight  or  7iil   51 


3.  Cases  in  which  marked  improve- 

ment   occurred    36 

4.  Cases  in  which  permanent  bene- 

fit was  obtained    25 

120 

Analysis  of  these  cases  shows  that 
far  better  results  could  be  obtained  by  . 
a  careful  adjustment  of  the  dosage  to 
the  actual  needs  of  each  individual  case. 
Addison's  disease  being  due,  from  the 
writer's  viewpoint,  to  inadequate  oxy- 
genation and  metabolic  activity,  the  re- 
sult in  turn  of  a  deficient  production  of 
the  adrenal  secretion,  it  follows  that 
tlie  temperature  and  blood-pressure  in- 
dicate the  degree  to  which  the  adrenals 
are  still  performing  their  functions.  It 
is  plain,  therefore,  that  our  aim  should 
be  to  supply  only  just  enough  adrenal 
extractive  to  compensate  for  the  defi- 
ciency of  adrenal  secretion  produced. 

The  25  cases  of  Addison's  disease  in 
which,  out  of  the  120  referred  to  above, 
permanent  benefit  occurred  include  one, 
treated  by  Bate,  in  which  but  M^  grain 
(0.005  Gm.)  of  adrenal  extract  three 
times  daily  caused  very  great  and  last- 
ing improvement  with  marked  lessening 
of  the  bronzing.  When  the  remedy 
could  not  be  obtained  temporarily, 
which  occurred  twice,  the  case  relapsed. 
On  the  other  hand,  Suckling  began  with 
10  grains  daily  and  gradually  increased 
until  175  grains  were  given  each  day, 
and  also  obtained  favorable  results. 
That  in  Bate's  case  the  adrenals  were 
still  able  almost  to  carry  on  their  func- 
tion is  self-evident,  while  in  Suckling's 
the  remedy  practically  compensated  for 
the  adrenals  (while  the  local  morbid 
process  in  them  was  still  active,  and 
such  as  to  paralyze  their  functions — a 
fact  well  shown  by  the  severity  of  the 
case  when  the  use  of  the  extract  was 
begun).  The  average  dose  is  probably 
that  used  by  Weigall  in  a  very  severe 
case — 5  grains,  increased  to  10  grains, 
of  the  extract  three  times  a  day.  The 
patient  increased  6  pounds  in  two 
weeks,  and  after  about  three  months  56 
pounds.  In  other  words,  in  the  25 
cases  of  permanent  benefit,  although 
the  remedy  was  used  empirically,  it  so 
happened    in    all    probability    that    the 


374  ADENITIS    (WITHERSTINE). 

doses  employed  coincided  with  the  needs  1.  Cases  in  which  death  can  be  ascribed 

of   the    organism.     In    the    51    cases    in  to  grafting  or  adrenal  preparations  .       8 

which   no   benefit   was   obtained   several  2.  Cases   in  which  benefit  was  sHght  or 

occur    in    which    failure    was    evidently  nil   51 

due  to  inadequate  dosage  or  to  too  early  3.  Cases   in   which   marked   improvement 

cessation    of    the    treatment,    while    in  occurred    36 

others    excessive    doses — practically    in  4.  Cases  in  which  permanent  benefit  was 

every  instance  a  too  rapid  or  excessive  obtained    25 

increase    of    the    dose — as    clearly    pre-  

vented     a     successful     issue.       Sajous  120 

(Monthly  Cyclo.,  April,  1909).  -piius,  adrenal  opotherapy,  while  it 

3.  The  injection  of  adrenahn  rec-  I'^mains  the  rational  mode  of  treat- 
ommended  by  Netter  and  Sergent  ap-  "'^^^  ^"  Addison's  disease,  requires 
pears  to  us  best  suited  for  the  cases  ^^""^  ^^^^  subject  be  kept  constantly 
showing  low  arterial  tension,  whether  ""^^^  supervision.  It  cannot,  there- 
of adrenal  orig-in  or  not.  ^°^^'  ^^   considered  a  harmless  form 

4.  Grafting  of  adrenal  tissue.     The  °^  medication. 

only    rational    treatment    for    adrenal  J'  ^-  Langlois, 
insufficiency  is  grafting  of  the  gland. 

Experimentation  shows,  indeed,  that         ADENITIS. —  DEFINITION.  

the  substances  secreted  by  the  gland  Inflammation  of  a  gland, 

are    very    quickly    destroyed    in    the  VARIETIES.  —  Adenitis     may    be 

organism,  and  that  either  the  inges-  acute,  due  almost  invariably  to  infection 

tion  or  injection  of  the  extract  can,  from  an  attack  of  angioleucitis  and  oc- 

therefore,   produce   but   very   evanes-  casionally    to    injury    or    strains;    or 

cent    effects,    which,    besides,    cannot  chronic,   resulting   from   either   of   the 

completely    replace   the    activities    as  preceding,    especially    in    strumous    or 

yet  unknown  having  their  seat  in  the  cachectic     persons,     and     from     slight 

glandular    cells    themselves.      Unfor-  sources   of   irritation,   and  not  uncom- 

tunately,  success  in  adrenal  grafting  monly  resulting  in  permanent  enlarge- 

is   not   easily   obtained,   and   in   cases  ment  and  induration  or  in  tuberculous 

where    the    vitality    of    the    grafted  degeneration.        Adenitis     of      specific 

gland  has  manifested  itself  accidents  origin  wih  be  described  under  Syphilis 

of  so  grave  a  nature  have  been  noted  and  Urinary  System. 

that  grafting  has  been  considered  an  ACUTE  ADENITIS. 

impracticable  method.     Courmont  re-  SYMPTOMS.— The   general    symp- 

ports  3  cases  of  the  grafting  of  dogs'  toms     depend    upon    the     extent    and 

adrenals   in   man   and   states   that   in  severity  of  the  infection.     Rigors  may 

all    of   them   the   results    were   disas-  occur  when  pus  forms.     The  tempera- 

trous.     His  personal   case   developed  ture  is  frequently  elevated.     If  the  in- 

a   formidable   hyperthermia   and   car-  fection  is  severe,  symptoms  of  profound 

diac  collapse.  septicemia  appear. 

Sajous  has  collected  from  the  gen-  The  local  symptoms  are,  by  far,  the 
eral  literature  120  cases  of  Addison's  most  prominent  in  the  majority  of  cases, 
disease  treated  by  opotherapy  in  its  and  consist  of  pain,  heat,  and  swelling, 
various  forms  and  presents  the  fol-  The  suffering  varies  from  a  slight  sore- 
lowing  table  : —  ness  only  to  intense  pain  according  to 


Adenitis  (witherstine). 


375 


the  position  of  the  gland,  its  relations 
with  the  surrounding  tissues,  and  the 
density  of  the  tissue  in  which  it  is  im- 
bedded. The  heat  may  vary  according 
to  the  degree  of  the  congestion  present. 
The  swelling  may  either  be  great  or 
slight.  If  the  lesion  be  confined  to  the 
gland,  it  will  be  well  defined;  if  peri- 
adenitis is  present,  the  swelling  will  be 
more  or  less  dift'use.  Glands  in  any  re- 
gion of  the  body  may  be  affected,  but 
those  of  the  neck,  axilla,  and  groin 
more  than  the  others ;  this  is  due  to  the 
fact  that  infection  generally  enters  the 
system  through  the  mouth,  throat, 
genital  organs,  and  the  extremities. 

In  the  congestive,  or  exudative,  stage, 
pain  and  swelling  are  present  in  the 
region  of  the  glands ;  if  the  glands  are 
superficial  the  swelling  is  ovoid,  with 
the  long  axis  coinciding  with  the  direc- 
tion of  the  afferent  lymphatics,  and  pal- 
pation reveals  several  movable,  hard, 
elastic,  and  tender  rounded  masses. 

When  the  glands  are  deep,  as  in  the 
axilla,  abdomen,  or  even  the  neck,  the 
results  of  palpation  are  less  definite  and 
unsatisfactory. 

In  the  suppurative  stage  the  pain  in- 
creases and  becomes  sharp  and  catch- 
ing, the  skin  reddens,  and  the  periglan- 
dular tissue  swells. 

If  the  gland  alone  suppurates,  the 
skin  remains  normal,  while  under  it 
may  be  felt  the  softened  and  enlarged 
gland.  This  latter  opens  outwardly  or 
into  the  neighboring  cellular  tissue  on 
from  the  sixth  to  the  fifteenth  day  of 
the  affection.  When  the  gland  opens 
outwardly,  the  cicatrix  is  much  smaller 
than  when  it  ruptures  into  the  cellular 
tissue,  as  in  the  latter  case  it  gives  rise 
to  an  abscess. 

If  the  cellular  tissue  around  the  gland 
suppurates,  the  skin  becomes  quite 
hot,  swollen,  and  painful,  and  fluctua- 


tion may  be  felt.  Two  foci  of  suppu- 
ration are  thus  established.  The  skin 
is  occasionally  undermined  by  the 
pus.  Recovery  is  possible,  however, 
without  suppuration  of  the  gland. 

Both  the  gland  and  the  cellular  tissue 
around  it  may  suppurate,  either  simul- 
taneously, or  suppuration  of  the  cellular 
tissue  may  precede  that  of  the  glands, 
or  the  latter  may  suppurate  and  rupture 
into  the  surrounding  cellular  tissue  and 
form  an  abscess.  Pus  is  usually  pro- 
duced in  considerable  quantity,  and  the 
affection  is  of  long  duration. 

Suppurative  adenitis  may  result  in 
cicatrization  after  several  weeks.  This 
cicatrix  may  reopen  to  allow  the  exit  of 
pus  from  a  suppurated  gland.  On  the 
other  hand,  a  fistula  may  result,  which 
may  give  exit  to  seropus  or  to  lymph 
(Despres).  A  lymphatic  gland  or 
vessel  will  then  be  found  at  the  bottom 
of  the  abscess  cavity,  below  the  crater- 
like opening. 

As  the  suppuration  usually  starts  in 
more  than  one  focus  in  the  gland,  the 
first  sensation  to  the  touch  will  be  one 
of  bogginess,  which  periglandular  con- 
gestion may  render  obscure.  Well- 
defined  fluctuation  is  found  only  when 
considerable  tissue  is  destroyed. 

The  writer  reports  the  case  of  a 
child  that  had  been  referred  to  him 
with  the  diagnosis  of  hypertrophy  of 
the  thymus  gland,  the  chief  symptoms 
being  dyspnea  and  retrosternal  dull- 
ness. On  operating  with  the  inten- 
tion of  removing  the  thymus  this  or- 
gan was  found  too  small  to  account 
for  the  symptoms,  but  deeply  behind 
the  sternum,  between  the  innominate 
artery  and  the  trachea,  the  author 
came  upon  a  grayish  mass,  which 
proved  to  be  a  suppurating  lymph- 
gland.-  This  and  another  large  node 
situated  at  the  side  of  the  trachea 
were  removed.  The  result  was  satis- 
factory, the  suffocative  attacks  being 
relieved.    The  lesson  drawn  from  this 


376 


ADENITIS    (WITHERSTINE). 


case  by  the  author  is  that  predomi- 
nance of  abdominal  recession  during 
inspiration,  as  against  almost  com- 
plete absence  of  suprasternal  and  sub- 
clavicular recession,  as  had  been  pre- 
viously noted  in  this  case,  is  a  point 
of  considerable  importance  in  the  dif- 
ferentiation of  mediastinal  periade- 
nitis from  thymus  enlargement.  Veau 
(Bulletin  med..  Mar.  1,  1911). 

DIAGNOSIS.— The  diagnosis  of 
ordinary  superficial  acute  adenitis  is 
usually  easy;  it  is  more  difficult  when 
the  neighboring  cellular  tissue  is  also 
inflamed;  it  may  be  impossible  in  cases 
of  deep-seated  or  visceral  adenitis. 

In  adenitis  of  the  inguinocrural  re- 
gion the  swelling  is  found  in  the  ex- 
ternal portion  of  the  region  if  due  to  a 
lesion  of  the  gluteal  tissues,  and  in  the 
inner  portion  of  the  region  if  due  to  a 
lesion  of  the  anus,  perineum,  or  external 
genitals.  In  both  conditions  the  tumor 
will  have  its  long  axis  directed  more  or 
less  horizontally. 

The  swelling  will  be  found  in  the 
lower  portion  of  the  inguinocrural  re- 
gion, with  the  long  axis  directed  more 
or  less  vertically,  if  the  lesion  causing  it 
is  situated  on  the  foot,  leg,  or  lower 
part  of  the  thigh.  This  disposition  is 
due  to  the  anatomical  relations  of  the 
lymphatic  vessels  and  glands,  and 
should  be  borne  in  mind.  Operation 
for  strangulated  crural  (femoral) 
hernia  has  been  performed  for  an 
adenophlegmon  of  the  crural  canal. 

Supraclavicular  adenitis,  while  fre- 
quent in  phthisis,  is  not  present  in  every 
case.  Yet  it  is  of  great  diagnostic  value 
when  present.  There  may  be  a  few  or 
a  great  number  of  slightly  enlarged 
glands,  and  they  are  frequently  bilat- 
eral. The  cervical  glands  may  also  be 
enlarged.  There  is  no  pain,  nor  does 
the  swelling  increase,  remaining  just 
the  same  for  years.  They  rarely  ac- 
company apical  tuberculosis,  but  are 
generally    found   with   peripheral,    sub- 


pleural  lesions.  The  writer  considers 
that  the  presence  of  enlarged  supra- 
clavicular glands  confirms  the  diagnosis 
of  doubtful  phthisis.  C.  Sabourin 
(Jour,  des  praticiens,  Dec.  27,  1902). 

New  sign  described,  based  on  aus- 
cultation at  level  of  seventh  cervical 
or  first  dorsal  vertebra.  When  the 
child  speaks  in  a  low  voice  the  voice 
sound  is  accompanied  by  an  added 
whispering  sound,  localized  to  one  or 
two  vertebras,  or  extending  even  to 
fourth  or  fifth  dorsal  vertebra.  It  is 
present  long  before  dullness  appears. 
The  bronchial  quality  of  respiration 
over  this  area  is  also  significant,  but 
it  only  appears  when  the  glands  are 
considerably  enlarged.  The  absence 
of  abnormal  breath  sounds  and  apical 
rales  afifords  corroborative  evidence. 
D'Espine  (Brit.  Med.  Jour.,  Oct.  15, 
1910). 

ETIOLOGY.— The  lymphatic  glands 
serve  as  reservoirs  on  the  course  of  the 
lymphatic  vessels,  through  which  any 
irritants  or  infection  must  pass. 

Cold  and  overexertion  act  as  local 
depressants,  and  thus  may  indirectly 
favor  the  development  of  adenitis.  Gen- 
eral debihty  has  the  same  effect.  The 
following  varieties  of  adenitis,  etiolog- 
ically  regarded,  are  recognized  : — 

1.  Adenitis  by  contiguity,  resulting 
from  the  propagation,  by  contact,  of  a 
neighboring  inflammation. 

2.  Adenitis  by  continuity  or  follow- 
ing lymphangitis. 

3.  Adenitis  by  embolism,  due  to  the 
transportation  of  septic  or  irritating 
matter,  produced  in  the  system  or  com- 
ing from  the  outside. 

Adenitis  of  the  mesenteric  glands 
may  be  due  to  dysentery  or  to  the 
inflammation  of  Peyer's  patches  in 
typhoid  fever. 

Adenitis  occurs  in  carbuncle,  furun- 
cle, vaccination,  erysipelas,  and  eruptive 
or  infectious  fevers. 

Attention  has  been  called  by  many 


ADENITIS    (WITHERSTINE). 


Z77 


observers  to  the  frequent  association  of 
enlargement  of  the  cervical  glands  and 
diseased  tonsils.  So  often  has  this  been 
found  that  every  patient  suffering  from 
cervical  adenitis  should  have  the  tonsils 
examined,  with  a  view  to  their  removal 
if  diseased.  The  contents  of  the  ton- 
sillar crypts  should  be  examined  mi- 
croscopically, and  the  identity  of  the 
bacterial  growths  therein  ascertained. 
It  is  wase  to  submit  the  tonsillar  mass 
to  bactericidal  measures — iodine  in 
glycerin,  for  example — sometime  be- 
fore removing  them. 

The  ordinary  operation  of  tonsillec- 
tomy removes  only  the  protruding  por- 
tion of  the  tonsil.  The  submerged 
tonsil,  which  frequently  extends  a  dis- 
tance of  one-half  to  three-fourths  of 
an  inch  into  the  tissues  of  the  neck, 
is  the  one  that  gives  the  most  trouble, 
and  is  the  one  that  is  the  most  difficult 
to  remove.  No  single  instrument  can  be 
relied  upon  for  the  removal  of  this  tis- 
sue. If  the  tonsil  is  situated  so  that  it 
can  be  drawn  out  by  forceps,  the  old 
guillotine  can  be  used,  but  this  only 
applies  to  a  limited  number  of  cases. 
Usually  the  tonsil  must  be  grasped  with 
forceps  and  carefully  cut  loose  from 
its  capsular  sheath,  after  which  it  is 
removed  by  the  wire  snare  or  guillo- 
tine. A  tonsillar  curette  is  valuable  for 
removing  the  masses  at  the  bottom  of 
the  cavities  which  have  been  left  after 
the  snare  or  punch  forceps.  The  tonsil 
may  be  drawn  from  its  bed  by  a  thread, 
which  is  found  often  more  useful  than 
the  forceps,  as  it  does  not  need  read- 
justing in  cases  of  bleeding  or  vomit- 
ing. As  a  rule  the  operation  can  be 
done  without  general  anesthesia.  In 
every  case  of  enlargement  of  the  lymph- 
glands  the  tonsils  should  be  thoroughly 
removed.  R.  C.  Myles  (Jour.  Amer. 
Med.  Assoc,  Oct.  29,   1904). 

The  writer  made  histological  ex- 
aminations of  65  whole  tonsils  re- 
moved from  children;  57  tonsils  of 
patients  not  clinically  tuberculous 
showed  no  tuberculous  lesions.  Of 
eight  patients  with  tuberculous  cervi- 


cal adenitis  the  tonsils  were  found  tu- 
berculous in  five.    In  two  of  the  cases 
there  was  evidence  of  other  than  ton- 
sillar source  for  the  tuberculous  in- 
fection.    F.  S.  Matthews   (Annals  of 
Surg.,  Dec,  1910). 
PATHOLOGY.  —  If      suppuration 
does    not    occur,    resolution    may    take 
place,    or   chronic    enlargement    of    the 
gland   may    follow    hyperplasia   of   the 
connective-tissue  stroma  of  the  gland. 

If  suppuration  does  occur  the  sur- 
rounding connective  tissue  may,  and 
usually  does,  suppurate;  then  the  more 
or  less  disintegrated  gland  lies  in  a  sup- 
purating cavity  formed  by  the  circum- 
jacent connective  tissue. 

There  are  two  forms  of  acute  ade- 
nitis, depending  upon  the  degree  of 
inflammation  present : — 

1.  Exudative  adenitis.  In  this  form 
the  gland  is  swollen,  and  it  feels  hard 
and  elastic.  On  section  it  appears  red- 
dish brown,  like  the  spleen,  with  small 
foci  of  hemorrhage,  all  of  which  indi- 
cate excessive  dilatation  of  the  capil- 
laries. The  lymphatic  stream  is  arrested 
by  the  dilatation  of  the  cortical  lymph- 
sinuses  and  their  obstruction  by  fibrin, 
granular  material,  and  portions  of 
altered  white  corpuscles.  The  lymph- 
follicles  are  filled  with  fibrin  and  accu- 
mulated lymph-cells.  The  stroma  of 
the  gland  is  swollen  and  infiltrated  with 
cells. 

If  the  section  of  the  gland  is  scraped, 
a  milky  liquid  will  be  obtained,  which 
contains  white  corpuscles  and  epithelial 
cells,  the  latter  showing  several  nuclei. 
2.  Suppurative  adenitis.  In  this  va- 
riety the  gland  softens,  its  tissues 
become  more  brittle,  hemorrhagic  infil- 
tration centers  form  that  soon  change 
into  yellow,  purulent  foci.  These,  at 
first  distinctly  separate,  soon  unite, 
forming  an  abscess  within  the  fibrous 
capsule  of  the  gland.     Sometimes  the 


378 


ADENITIS    (WITHERSTINE). 


periglandular  tissue  suppurates,  while 
the  gland  does  not. 

The  glandular  abscess  and  the  peri- 
glandular abscess  may  open  externally, 
each  one  separately  or  both  simulta- 
neously. The  suppurating  gland  may 
rupture  into  the  cellular  tissue.  Occa- 
sionally the  gland  is  hard  and  elastic ;  it 
may  be  difficult  to  separate  it  from 
its  fibrous  capsule.  The  afferent  lym- 
phatics are  enlarged  and  thickened. 
The  lymph-cells  and  cortical  follicles 
are  few  in  number  and  have  under- 
gone granulofatty  degeneration. 

PROGNOSIS.— The  prognosis  is 
usually  favorable ;  it  may  be  unfavor- 
able, however,  when  extensive  abscesses 
form  in  the  neighborhood  of  important 
organs. 

Deep-seated  suppurative  adenitis  may 
give  rise  to  dangerous  complications, 
especially  in  certain  regions,  like  the 
neck  and  mediastinum,  on  account  of 
the  purulent  extensions  (through  bur- 
rowing) and  the  difficulty  of  evacuating 
the  pus. 

Ulceration  of  the  great  vessels  of  the 
neck  giving  rise  to  grave  hemorrhages 
may  also  occur. 

TREATMENT.— The  first  indica- 
tion in  acute  adenitis  is  to  remove  any 
source  of  irritation  or  infection.  Any 
wound,  abrasion,  opening,  or  any 
natural  cavity  with  which  either  of 
these  may  connect  should  be  so  treated 
as  to  bring  about  absolute  local  asepsis. 

Enlarged  glands  of  the  neck  are  not, 
primarily,  tubercular,  and  bear  the 
sHghtest  relation,  if  any,  to  general  or 
pulmonary  tuberculosis.  The}'-  are  due 
to  a  mixed  infection  of  pus-producing 
bacilli,  and  will  quickly  resolve  if  the 
source  of  the  infection  is  removed  be- 
fore the  glandular  tissue  becomes  dis- 
organized. If  disorganization  takes 
place,  the  gland  should  be  poulticed 
until  it  is  practically  liquefied.  It  should 
then  be  opened  by  a  stab  puncture,  emp- 


tied and  drained  by  a  Briggs  cannula. 
Cases  seen  late  with  a  large  mass  of 
partially  calcified  and  partially  disor- 
ganized glands  present  call  for  a  thor- 
ough and  extensive  dissection.  Treat- 
ment, other  than  local,  should  be  food, 
fresh  air,  and  proper  clothing.  F.  D. 
Donoghue  (Boston  Med.  and  Surg. 
Jour.,  Mar.  28,  1907). 

The  region  in  which  the  affected 
gland  is  situated  should  be  kept  at  rest 
and,  if  possible,  elevated.  In  this  man- 
ner the  afferent  arterial  current  is 
diminished,  while  the  efferent  venous 
and  lymphatic  currents  are  increased. 

To  prevent  suppuration,  gray  mer- 
curial ointment,  very  gently  rubbed  in, 
is  useful.  The  injections  of  from  5  to 
10  minims  of  a  3  per  cent,  carbolic  acid 
solution  into  an  inflamed  gland  have 
also  proven  satisfactory. 

If  it  is  desired  to  hasten  suppuration, 
warm  antiseptic  fomentations  are  to  be 
used  in  preference  to  poultices.  The 
compound  resin  cerate  of  the  pharma- 
copoeia is  effective  for  this  purpose,  and 
is  antiseptic  as  well. 

When  pus  has  formed,  the  gland 
should  be  opened  by  a  generous  inci- 
sion, sinuses,  if  present,  being  opened 
throughout  their  entire  length  to  facili- 
tate treatment.  The  contents  are  then 
carefully  removed,  and  the  infiltrated 
•wall  scraped  with  a  sharp  curette.  The 
cavity  should  then  be  packed  with  iodo- 
form gauze,  or  gauze  impregnated 
with  camphorated  naphthol  or  salol. 
The  dressing  may  be  removed  on  the 
third  day. 

Sufficient  attention  has  not  been  paid 
to  the  subject  of  wholly  avoiding  or  at 
at  least  minimizing  the  scar  in  the  sur- 
gical treatment  of  cervical  adenitis. 
Many  cases  of  cervical  adenitis  occur 
in  which  this  is  of  great  importance, 
and  in  which  radical  operative  meas- 
ures are  not  demanded.  In  such  cases 
aspiration,  or  the  use  of  a  seton,  or 
both,    while    not    infallible,    may   prove 


ADENITIS    (WITHERSTINE). 


379 


successful.  When  the  tuherculous 
glands  do  not  subside  under  medical 
treatment,  excision,  done  with  extreme 
care  and  reasonably  early,  is  the  method 
of  choice.  Neither  aspiration  nor  the 
use  of  a  seton  should  be  resorted  to  in 
cases  involving  the  deep  cervical  glands. 
Bulkley  (Amer.  Med.,  Feb.  27,  1904). 
In  addition  to  climatic  and  general 
tonic  treatment,  the  writer  advised  the 
evacuation  by  puncture  of  suppurative 
adenitis  and  the  injection  of  a  mixture 
of  iodoform,  1  part;  ether,  10  parts; 
oil  of  sweet  almonds,  100  parts;  creo- 
sote, 2  parts.  In  chronic  cases  cure  may 
be  obtained  in  two  or  three  months 
after  about  twenty  punctures.  Robin 
(Tribune  med.,  xli,  249,  1908). 

Balsam  of  Peru  is  a  valuable  curative 
agent,  as  it  is  not  only  antiseptic,  but  is 
a  stimulant  to  healthy  granulation.  It 
is  applied  directly  to  the  open,  cleansed 
wound,  and  then  covered  with  gauze 
and  ^retaining  bandage. 

In  the  treatment  of  cases  of  simple 
chronic  adenitis,  applications  of  iodine, 
compression,  and  local  blistering  have 
given  the  best  results. 

Blisters,  nitrate  of  silver,  or  iodine 
tincture  should  be  applied  around,  but 
not  over,  the  inflamed  gland. 

Excision  may  be  performed  if  the 
mass  be  large  or  disfiguring. 

In  cervical  adenitis  due  to  tonsillar 
infection  some  authors  have  strongly 
advised  the  thorough  removal  of  the 
diseased  tonsil  before  attempting  the 
external  operation  upon  the  glands, 
especially  in  those  cases  in  which  the 
lymph-glands  have  not  broken  down. 
The  extension  of  the  infection  through 
the  lymphatics  from  the  tonsils  is  thus 
checked. 

In  cervical  adenitis  due  to  tonsillar 
infection,  the  writer  removes  the  dis- 
eased tonsil  itself  before  attempting  the 
external  operation,  in  cases  where  the 
lymph-glands  have  not  broken  down. 
The  cervical  glands  receive  their  lym- 
phatics from  the  tonsils,  arfd  the  exten- 


sion of  the  infection,  a  conuuon  occur- 
rence, is  thus  checked.  Five  cases  re- 
ported in  which  the  neck  swelling  dis- 
appeared after  removal  of  the  diseased 
tonsillar  tissue.  Some  of  these  cases 
had  advanced  to  a  considerable  involve- 
ment of  the  cervical  glands.  A.  E. 
Rogars  (Med.  Rec.  Nov.  28,  1903). 

Electricity,  preferably  the  constant 
current,  is  highly  recommended  by  some 
authors.  Daily  sittings  of  ten  minutes 
each,  using  5  to  15  milliamperes,  are 
required. 

Codliver  oil,  the  iodides,  and  iron 
are  indicated  in  all  cases  when  the 
digestive  organs  do  not  rebel  against 
their  use.  Arsenic  and  strychnine  are 
the  agents  next  in  order,  and  sometimes 
I)rove  very  eft'ective.  Out-of-door  life 
and  plentiful  nourishment  are  of  pri- 
mary importance. 

CHRONIC  ADENITIS. 

SYMPTOMS.— The  symptoms  vary 
according  to  the  period  of  development 
in  which  the  diseased  gland  is  found  at 
the  time  of  examination. 

Three  periods  of  development  are 
commonly  recognized  in  tuberculous 
adenitis :  the  period  of  induration,  or 
indolence;  the  period  of  inflammation, 
and  the  period  of  suppuration. 

1.  Period  of  Induration,  or  Indo- 
lence.— This  period  may  last  for  years, 
and  resolution  may  even  take  place, 
though  the  gland  always  remains  some- 
what enlarged  and  indurated.  The 
glands  are  felt  as  hard,  elastic,  enlarged 
bodies,  rolling  under  the  finger,  with 
more  or  less  distinctness  as  they  are 
situated  superficially  or  deep.  No  heat, 
pain,  or  redness  of  the  skin  is  perceived. 

2.  Period  of  Inflammation. — In  this 
period  we  have  pain,  redness  of  the 
skin,  and  tenderness  on  pressure.  The 
gland,  if  solitary,  may  adhere  to  the 
skin.     Fluctuation  may  be  present. 


380 


ADENITIS    (WITHERSTINE). 


3.  Period  of  Suppuration. — In  this 
period  we  notice  much  more  softening 
of  the  contents  of  the  gland  than  a  real 
suppuration.  The  skin  may  ulcerate 
through  almost  without  inflammatory 
symptoms,  and  the  contents — consisting 
of  caseous  matter  half-dissolved  in  a 
whitish  watery  fluid — may  be  evacuated. 
When  periadenitis  occurs,  true  pus  may 
be  present. 

If  chains  of  glands  are  tuberculous, 
the  latter  inflame  alternately  and  dis- 
charge their  contents  in  the  same  order, 
a  series  of  abscesses  being  thus  formed. 

When  the  contents  of  the  gland  are 
discharged,  the  skin  may  become  ulcer- 
ated in  the  neighborhood,  form  fistula, 
and  after  heahng  leave  a  depressed, 
adherent,  violet-colored  cicatrix. 

In  some  cases  a  fistula  may  form  and 
last  for  years;  the  skin  may  be  under- 
mined, and  disfiguring  cicatricds  may  be 
formed. 

Cretaceous  transformation  occurs  at 
times  in  the  deeper  glands,  but  rarely 
in  the  superficial  ones.  Some  caseous 
glands  undergo  a  process  which  trans- 
forms them  into  a  cyst-like  cavity  con- 
taining a  serous  liquid. 

In  chronic  adenitis  the  glands  may 
become  painful  by  the  compression  of 
small  nerves,  or  of  neighboring  organs ; 
when  they  are  inflamed  a  small,  hard 
mass  usually  appears,  either  alone  or 
united  with  others,  which  may  become 
enlarged  and  suppurate,  or  persist  with 
practically  no  change  for  years,  or 
finally  disappear  if  the  cause  of  irrita- 
tion be  removed. 

Chronic  adenitis  may  assume  various 
forms. 

1.  General  Tuberculous  Adenitis. — 
This  presents  itself  especially  in  ne- 
groes. Organs  other  than  the  glands 
are  but  little  affected,  and  continuous 
fever  exists.    The  retroperitoneal,  bron- 


chial, and  mesenteric  glands  are  the 
most  enlarged.  It  resembles  in  many 
ways  an  acute  attack  of  Hodgkin's 
disease. 

The  majority  of  children  presenting 
symptoms  of  tuberculosis  also  have 
general  adenitis,  the  swollen  glands 
being  felt  everywhere ;  they  never 
change  in  size  or  consistence.  Sud- 
denly a  bronchitis  develops,  followed 
by  a  bronchopneumonia,  from  v/hich 
the  child  dies.  Microscopical  examina- 
tion reveals  caseous  spots  and  the  pres- 
ence of  tubercle  bacilli  throughout  the 
affected  glands.  The  name  of  "gener- 
alized peripheral  adenitis"  is  suggested 
for  this  condition.  Grancher  and  Mari- 
nescu  (L'Union  Med.,  Dec.  2,  1890). 

2.  Local    Tuberculous    Adenitis. — 

(a)  Cervical.  This  form  is  usually 
met  with  in  children,  and  begins  in  the 
submaxillary  glands,  wdiich  are  gener- 
ally more  enlarged  on  one  side. 

(b)  Bronchial.  This  form  is  thought 
to  be  always  secondary  to  a  focus  in  the 
lungs,  by  some  authors,  but  this  opinion 
is  contested  by  many  others.  Osier 
among  them.  Local  lung  infection, 
pericardial  infection,  and  general  infec- 
tion are  to  be  feared,  however. 

(c)  Peribronchial.  In  this  form  we 
must  realize  the  importance  of  lesions 
resulting  from  caseation.  There  is  a 
softening  of  the  lymphatic  glands  situ- 
ated around  the  lower  end  of  the 
trachea  and  main  bronchi.  Evidence 
from  percussion  is  of  doubtful  value ; 
alterations  in  breath-sounds  are  much 
more  important,  especially  when  uni- 
lateral; divided  respiration,  with  pro- 
longed expiration,  is  found  unaccom- 
panied by  any  adventitious  sounds.  In 
cases  in  which  the  enlarged  glands 
ulcerate  through  the  air-tubes,  the 
breath  has  a  very  offensive  odor,  and 
coexistence  of  fetor  with  hemoptysis 
and  evidence  of  pulmonary  consolida- 
tion is  suggestive.     When  vomiting  of 


ADENITIS    (WITHERSTINE). 


381 


blood  and  its  passage  by  ll)o  bowel  arc 
added,  tbc  diagnosis  of  glands  ruptur- 
ing into  tbc  bronchus  and  esophagus 
is  the  nuvst  likely  one. 

General  tuberculous  adenitis  is 
likely  to  occur  in  such  cases  unless 
prompt  remedial  measures  are  insti- 
tuted. 

(d)  Mesenteric.  This  form  may  be 
primary,  and  is  thus  very  common  in 
children,  or  secondary  to  local  intestinal 
tuberculosis.  The  sufferers  are  usually 
weak  and  wasted;  the  abdomen  is  en- 
larged and  tympanitic,  and  diarrhea  is 
a  common  symptom.  Some  fever  is 
usually  present.  This  form  may  exist 
in  adults. 

Sims  Woodhead  found  tuberculous 
mesenteric  glands  in  78.7  per  cent.  o£ 
necropsies  on  tuberculous  children,  and 
in  11  per  cent,  the  mesenteric  was  the 
only  lesion  present.  Colman  found 
them  in  66  per  cent,  of  the  necropsies; 
Walter  Carr  in  54  per  cent. ;  W.  P.  S. 
Branson  in  22  per  cent.  When  this  con- 
dition is  present  in  adults,  it  is  found 
to  affect  most  frequently  the  glands  of 
the  appendix,  or  of  the  ileocecal  region, 
because,   according  to   Corner : — 

1.  The  cecum  is  like  the  stomach,  a 
resting  place  for  the  bowel  contents  in 
its  passage. 

2.  The  bowel  contents  contains  a 
maximum  number  of  organisms  in  the 
cecum. 

3.  The  lymphoid  tissue  has  its  great- 
est development  in  the  ileum,  the  cecum, 
and  especially  the  appendix.  Louis 
Rassieur  (Jour.  Missouri  State  Med. 
Assoc,  Feb.,  1909). 

DIAGNOSIS. — Chronic  adenitis  is 
generally  limited  to  one  or  two  glands ; 
when  the  glands  are  tuberculous, 
chronic  adenitis  is  apt  to  affect  an 
entire  mass.  The  former  is  often  asso- 
ciated with  an  external  simple  lesion; 
the  tuberculous  form  is  apt  to  be  more 
frequent  in  children,  young  soldiers, 
and  negroes. 

A  fragment  of  the  suspected  tissue 


may  l)e  implanted  into  the  subcutaneous 
connective  tissue  of  the  groin  of  a 
guinea-pig,  and  if  the  specimen  is  tuber- 
culous a  miliary  tuberculosis  will  de- 
velop in  from  five  to  six  weeks. 

The  use  of  the  tuberculin  test  in  the 
diagnosis  of  tuberculous  adenitis  is 
reliable  and  harmless.  The  tubercuhn 
used  is  a  1  per  cent,  solution  of  Koch's 
original  product,  from  1  to  5  mg.  con- 
stituting a  usual  dose. 

If  in  from  six  to  twenty-four  hours 
after  the  injection  of  tuberculin  solu- 
tion there  occur  weakness,  sensations 
of  heat  and  cold,  general  malaise, 
nausea,  anorexia,  severe  headache, 
pain  in  the  back  and  limbs,  and  if 
these  symptoms  are  sharply  defined 
in  both  their  beginning  and  ending, 
reaction  is  considered  to  have  oc- 
curred. 

Supraclavicular  adenitis,  while  fre- 
quent in  phthisis,  is  not  present  in  every 
case.  It  is,  however,  of  great  diagnostic 
value  when  present.  There  may  be 
few  or  many  slightly  enlarged  glands, 
and  they  are  frequently  bilateral. 

Lymphadenoma. — This  variety  of 
tumor  is  usually  more  voluminous  and 
is  not  suppurative.  The  diagnosis,  how- 
ever, is  exceedingly  difficult. 

Simple  Adenitis.— This  is  an  acute 
affection  usually  ending  in  a  few  days 
in  suppuration. 

Syphilitic  Adenitis.— When  a  pri- 
mary sore  is  present,  numerous,  small, 
hard,  indolent  glands  can  be  felt  if  the 
region  is  supplied  with  a  chain  of  lym- 
phatics. When  in  secondary  syphilis 
there  is  glandular  enlargement,  a  large 
number  of  external  lymphatics  take 
part  in  the  process. 

Carcinoma. — The     enlarged     glands 
are  small  and  hard,  and  can  generally 
be  distinctly  traced  to  the  growth. 
Lymphosarcoma.  —  This      persists 


382 


ADENITIS    (WITHERSTINE). 


longer  and  is  much  larger  before  de- 
generation occurs. 

Chronic  adenitis  is  frequently  a  com- 
plication of  malignant  tumors.  Supra- 
clavicular adenitis  appearing  during  the 
course  of  visceral  cancer  is  usually  situ- 
ated on  the  left  side  (found  27  times 
on  that  side  by  one  author).  It  may 
be  solitary  or  accompanied  by  adenitis 
in  other  regions ;  it  usually  appears  late 
and  develops  rather  rapidly.  When 
occurring  early  it  may  be  very  useful 
for  diagnostic  purposes. 

From  a  clinical  point  of  view  this 
adenitis  may  be  known  by  its  ligneous 
hardness,  its  painlessness,  its  freedom 
from  adhesions,  and  by  the  union  into 
one  solid  mass  of  all  the  glands  forming 
it. 

ETIOLOGY.— This  form  of  adeni- 
tis frequently  follows  some  neighboring 
superficial  lesion,  such  as  eczema, 
impetigo,  conjunctivitis,  or  the  exan- 
themata. Catarrhal  inflammation  of 
the  mucous  membranes  predisposes  to 
tuberculosis  of  the  glands.  The  resist- 
ance of  the  lymph-tissue  is  weakened. 
This  explains  the  frequent  development 
of  tuberculous  bronchial  adenitis  after 
whooping-cough  and  measles,  and  of 
mesenteric  adenitis  in  children  with 
intestinal  disturbances. 

Cervical  adenitis  is  not  a  manifesta- 
tion of  an  already  generalized  tuber- 
culosis ;  the  bacillus  penetrates,  by  solu- 
tion of  continuity  of  the  mucous  mem- 
branes or  the  skin,  to  the  ganglion, 
which  becomes  a  seat  of  infection 
(Duhamel). 

Enlarged  glands  of  the  neck  are  not, 
primarily,  tubercular,  and  bear  the 
slightest  relation,  if  any,  to  general  or 
pulmonary  tuberculosis.  They  are  due 
to  a  mixed  infection  of  pus-producing 
bacilli,  and  will  quickly  resolve  if  the 
source    of    the    infection    is    removed 


before  the  glandular  tissue  becomes 
disorganized. 

A  distinction  should  be  made  between 
hereditary  (congenital)  and  acquired 
tuberculosis.  In  the  latter  case  the 
author's  views  seem  rational  and  cor- 
rect, being  comparable  with  and  analo- 
gous to  the  phenomena  observed  in 
carcinoma  and  syphilis.  When  the  in- 
fection is  acquired  there  is,  at  first,  a 
local  seat,  or  focus,  of  infection  in 
which  the  disease  germs  develop  and 
from  which,  after  proliferation,  they 
spread  tmtil  the  disease  becomes  more 
or  less  generalized, — the  germs  being 
transmitted  through  the  lymphatic  sys- 
tem to  the  lungs  and  thence  in  the 
blood-stream  to  the  various  organs  of 
the  body;  the  various  glands  along  the 
course  or  path  of  transmission  become 
affected  and  in  turn  become  additional 
possible  foci  of  infection.  On  the  other 
hand,  when  the  trouble  is  hereditary 
the  glandular  manifestation  is  an  indi- 
cation of  an  already  generalized  tuber- 
culosis. 

Youth  predisposes  to  caseous  adenitis 
on  account  of  the  predominance  at 
that  period  of  the  lymphatic  system. 
Crowding,  humidity,  and  bad  or  insuffi- 
cient food  are  also  predisposing  factors. 
Tuberculous  adenitis  is  frequently  ob- 
served in  temperate  regions.  Negroes 
brought  to  such  climates  are  especially 
prone  to  become  sufferers. 

The  absorbent  power  of  the  lym- 
phatic system  is  so  great  that  the  mor- 
bific principle  of  tuberculosis  may  be 
transported  to  the  glands  without  visible 
external  lesion  of  the  skin  or  mucous 
membrane. 

Axillary  adenitis  is  frequently  sec- 
ondary to  chronic  tubercular  lesions  of 
the  lungs  (Lepine). 

The  cervical  glands  are  occasionally 
found  affected  in  phthisical  patients. 


ADENITIS    (WITHERSTINE). 


383 


Observations  by  Mitcbell,  of  Johns 
Hopkins  Hospital,  ni)on  170  cases  of 
tuberculous  cervical  adenitis  show  the 
disease  to  be  more  prevalent  among 
negroes  than  among  whites,  males  pre- 
ponderating over  females  in  the  pro- 
portion of  3  to  2,  the  majority  being 
between  10  and  30  years  of  age.  A 
family  history  of  tuberculosis  was  pres- 
ent in  about  half  the  cases,  though  only 
4  per  cent,  showed  positive  evidence  of 
the  disease  in  the  lungs.  The  condition 
is  regarded  as  a  local  manifestation  of 
infection  through  the  tonsils,  adenoids, 
or  carious  teeth. 

PATHOLOGY.— Usually  an  entire 
group  of  glands  is  atTected.  The  glands 
are  isolated  when  the  irritation  and 
rapidity  of  growth  are  not  great;  this 
usually  occurs  in  secondary  visceral 
adenitis.  In  other  cases — especially 
when  the  glands  are  superficial,  where 
the  adenitis  is  primary — the  glands  are 
united  into  a  large  lobulated  and  irregu- 
lar mass,  the  size  of  which  may  vary 
from  that  of  a  small  nut  to  that  of  an 
orange. 

If  the  adenitis  follows  a  visceral 
tuberculosis  the  afferent  lymphatics 
show,  in  some  cases,  signs  of  tubercu- 
losis, as  is  the  case  in  pulmonary  and 
mesenteric  tuberculous  meningitis. 

Two  varieties  of  lesions  are  to  be 
noted:  1.  Lesions  of  chronic  adenitis 
affecting  the  stroma  and  the  elements 
of  the  gland,  which  becomes  hyper- 
trophied.  2.  Specific  lesions  of  tuber- 
culosis,, consisting  in  miliary  granula- 
tion at  first,  ending  in  caseation.  As 
one  or  the  other  of  these  two  processes 
is  the  more  prominent,  so  will  the  lesion 
vary  in  appearance.  Deep  adenitis  is 
never  so  sclerous  as  the  superficial 
variety,  the  latter  being  characterized 
by  a  more  vigorous  reaction. 

On  section  of  a  gland  in  the  early 


stage  of  tuberculous  infection  we  find 
it  redder  than  usual,  though  at  times 
gray  and  somewhat  translucent.  The 
tuberculous  granules  may  be  perceived 
by  a  glass.  They  are  formed  from  the 
vascular  and  lymphatic  vessels  found 
in  the  cortical  and  medullary  portions, 
and  resemble  ordinary  follicles,  but 
contain  many  small  cells.  Caseation 
rapidly  occurs  in  them,  beginning  at  the 
center  of  the  cells,  where  giant-cells  are 
first  formed,  proceeding  to  coagulation 
necrosis  and  caseation.  A  number  of 
these  granulations  united  form  the 
small,  yellowish  masses,  which  may  be 
seen  by  the  unaided  eye.  Caseation  is 
due  to  vascular  obliteration. 

The  small,  yellowish  masses,  softened 
at  their  centers,  are  surrounded  by 
fibrous  tissue  due  to  sclerosis  of  the 
stroma  of  the  gland.  When  this  tissue 
gives  way,  several  masses  form  a  large 
collection  of  yellowish,  softened  material 
resembling  putty.  Calcification  may 
occur  when  the  process  is  very  slow. 

The  specific  lymphadenitis  blocks  the 
lymph-spaces  and  thus,  for  a  time  at 
least,  mechanically  prevents  the  bacilli 
from  penetrating  into  the  general  circu- 
lation. Glands  not  in  the  stream  become 
infected,  this  probably  being  due  to  the 
transportation  by  migrating  cells  of  the 
motionless  bacillus.  However,  infec- 
tion usually  takes  place  in  the  direction 
of  the  lymph-current.  As  the  lymph- 
spaces  are  obstructed  by  inflammation 
products,  and  entrance  of  fresh  bacilli 
into  the  gland  is  thus  prevented,  it  is 
the  multiplication  of  those  already 
entered  into  the  gland  which  gives  rise 
to  the  tuberculosis.  When  caseation 
occurs,  nearly  all  the  bacilli  have  dis- 
appeared, but  the  spores  remain,  and 
are  capable  of  reproducing  the  disease. 
Suppuration  is  due  to  a  secondary  in- 
fection by  pyogenic  micro-organisms. 


384 


ADENITIS    (WITHERSTINE). 


The  virus  of  tubercular  adenitis  is 
less  potent,  for  the  caseous  material  of 
a  lymph-gland  kills  guinea-pigs,  while 
rabbits  escape,  the  latter  being  less  sus- 
ceptible to  tuberculous  infection. 

Taken  as  a  whole,  tuberculous  adeni- 
tis (a)  is  a  local  disease  which  may  fre- 
quently undergo  (b)  spontaneous  reso- 
lution, but  which  (c)  frequently  tends 
to  suppuration,  the  pus  being  nearly 
always  sterile.  It  is,  however,  a  con- 
stant danger  to  the  system. 

Chronic  adenitis  may,  in  some  cases, 
be  due  to  continued  irritation;  ulcers; 
chronic  lesions  of  the  skin  or  mucous 
membrane  of  the  bones ;  periosteum ; 
articulations ;  chronic  inflammation  of 
the  viscera,  and  certain  new  growths 
where  the  adenitis  is  purely  irritative 
and  not  yet  specific. 

PROGNOSIS.— A  chronic  adenitis 
may  end  in  resolution,  suppuration — 
caseation  (see  Pathology),  cretaceous 
formation,  or  cyst  formation.  If  all 
the  tuberculous  matter  can  be  elimi- 
nated, either  by  nature  or  art,  a  re- 
covery may  be  obtained.  The  deeper 
glands  are  more  dangerous  than  the 
superficial,  as  they  are  extirpated  with 
more  difficulty.  The  great  danger  of 
local  tuberculous  adenitis  is  that  it  may 
give  rise  to  other  tuberculous  lesions, 
either  local  (pulmonary  phthisis,  tuber- 
culous osteitis,  white  swellings,  or  ab- 
scesses) or  general  (generalized  tuber- 
culosis, with  rapid  death). 

Acute  miliary  tuberculosis  may  be 
caused  in  two  ways :  either  by  convey- 
ance through  the  lymphatic  system 
until  the  venous  system  is  reached  or 
by  the  perforation  of  a  vein  and 
the  entrance  of  tuberculous  material 
(Weigert). 

TREATMENT.— The  general  treat- 
ment should,  in  all  cases  of  adenitis, 
receive  considerable  attention.     Good 


food,  country  air,  and  sea  bathing  are 

of  the  greatest  value. 

In  peribronchial  adenitis  the  same 
general  methods  are  to  be  resorted  to. 
When  due  to  tuberculosis  and  kindred 
diatheses  and  uncomplicated  by  fever 
or  involvement  of  lung-tissue,  the  sea- 
shore or  the  country  is  indicated.  At 
the  seaside  children  should  not  bathe  in 
the  sea,  and  should  be  as  quiet  as  is 
consistent  with  life  in  the  open  air. 
Brisk  frictions,  milk,  a  nutritious  diet, 
and  iodotannic  syrup  (2  to  4  teaspoon- 
fuls  per  day)  are  effectual  measures. 
After  three  to  four  weeks,  emulsion  of 
calcium  lactophosphate  and  codliver 
oil  should  be  given.  Counterirritation 
between  the  shoulder-blades  favors  the 
curative  action  of  the  other  remedies 
(Marfan).  AppHcations  of  tincture  of 
iodine  between  the  shoulders,  or  in 
some  cases  blisters  or,  even  better, 
ignipuncture,  will  fulfill  the  latter  indi- 
cations. The  syrup  of  the  iodide  of 
iron,  tincture  of  iodine,  potassium  io- 
dide, or  large  doses  of  codliver  oil, 
already  mentioned,  either  alone  or 
with  cinchona  wine,  arsenic,  or  ar- 
seniate  of  sodium,  are  the  standard 
remedies  usually  recommended  in 
these  conditions.  Not  much  is  to  be 
expected  from  them,  however,  unless 
outdoor  life  is  insisted  upon. 

Extirpation  is  indicated  when  internal 
medication  has  failed;  when  glands 
involve  the  face  and  produce  deformity ; 
when  they  are  isolated  and  few  in 
numbers ;  when  they  have  undergone 
fibrous  degeneration;  when  they  are 
not  freely  suppurating.  It  is  con- 
traindicated  when  there  is  impaired 
general  health  and  tubercular  deposits 
in  the  lungs  and  joints;  when  ramifica- 
tions of  the  chain  of  glands  are  very 
extensive. 

The  possibility  of  giving  rise   to  a 


ADENITIS    (WITHERSTINE). 


385 


tuberculous  process  elsewhere  by  facili- 
tating absorption  through  exposed  tis- 
sues should  be  borne  in  mind. 

One  thousand  cases  of  extirpation  of 
tuberculous  glands,  without  a  single 
case  of  pyemia  or  septicemia  and  with 
only  2  cases  of  erysipelas,  in  both  of 
which  the  infection  was  traced  to  a 
nurse.  One  of  the  best  criterions  of 
the  success  is  the  ever-increasing  num- 
ber of  patients  who  present  themselves 
for  operation,  and  who  nearly  all  enter 
the  hospital  asking  for  the  removal  of 
their  enlarged  glands.  Milton  (St. 
Thomas's  Hospital  Reports,  vol.  viii). 
Out  of  335  children  treated,  the  tuber- 
culous glands  were  removed  in  102. 
The  operated  cases  gave  a  percentage 
of  83.34  cured,  and  the  non-operated 
68.77  per  cent.,  that  is,  14.56  per  cent, 
in  favor  of  the  operation.  Generaliza- 
tion of  the  disease  could  be  found  only 
in  1  per  cent,  of  the  cases.  Cazin 
(Lyon  Med.,  Jan.   11,   1890). 

Five  hundred  and  six  cases:  286 
operated;  220  medically  treated.  Of 
the  operated  cases  149  were  carefully 
followed  during  three  years ;  93  (62.4 
per  cent.)  have  not  shown  the  least 
sign  of  return  of  the  affection.  In  the 
remaining  56  cases  there  was  a  return. 
Of  the  149  non-operated  cases,  28  died 
in  sixteen  years  (18  per  cent.)  from 
general  tuberculosis,  and  14  are  still 
alive,  but  have  developed  pulmonary 
tuberculosis.  Von  Noorden  (Schmidt's 
Jahrbucher,  July,   1890). 

In  the  cases  of  tubercular  adenitis 
which  are  not  yet  suppurating,  extirpa- 
tion through  a  small  incision  is  indi- 
cated at  once,  with  medical  after-treat- 
ment to  prevent  recurrence.  When  one 
hard,  caseous  nodule  exists,  it  should 
at  once  be  extirpated,  unless  the  result- 
ing scar  will  cause  marked  deformity. 
When  these  are  multiple,  immediate 
extirpation  is  the  treatment  to  be  fol- 
lowed. Should  the  adenitis  become 
purulent,  extirpation  is  only  indicated 
after  all  other  methods  of  treatment 
have  failed.  Local  injections  are  ad- 
vised, with  a  long  sojourn  at  the  sea- 
shore, especially  should  fistulae  occur. 
Clean  dressings  must  be  applied  to  the 


fistute  to  prevent  secondary  infection. 
When  extirpation  is  done,  it  should  be 
complete.  A.  Broca  (Jour,  des  Prati- 
ciens,  Oct.  26,  1901). 

Senn  states  that  early  operative  in- 
terference is  as  necessary  in  the  treat- 
ment of  tubercular  adenitis  as  in  the 
treatment  of  malignant  tumors,  and 
holds  out  more  encouragement,  so  far 
as  a  permanent  cure  is  concerned. 
Tillmann  argues  that  glandular  tuber- 
culosis should  be  operated  as  soon  as 
possible,    in   order   to  prevent   general 


Sigmoid  incision  for  the  removal  of  cervical 
glands.      (Senn.) 

miliary  tuberculosis  by  the  passage  of 
the  bacilli  into  the  system. 

After  incision,  thorough  curetting 
followed  by  iodoformization  and  clos- 
ure should  be  performed.  The  wound 
should  be  drained.  The  operator  should 
not  only  feel,  but  see,  every  gland  he 
removes.  In  cervical  adenitis  an 
S-shaped  incision  gives  more  room  and 
a  better  cicatrix. 

In  other  regions  the  incision  should 
be  made  so  as  to  bring  its  axis  parallel 
with  the  cutaneous  folds.  Local  recur- 
rence should  be  treated  in  the  same 
way.  Three  or  four  operations  in  as 
many  years  have  been  performed  by 
Senn  on  the  same  patient,  with  final 
successful  result. 


1—25 


386 


ADENITIS    (WITHERSTINE). 


Mitchell,  of  Johns  Hopkins  Hospital, 
uses  a  T-shaped  incision  when  making 
a  radical  operation  for  removing  all  the 
glands  and  surrounding  fat.  The  long 
arm  of  this  incision  is  made  to  curve 
forward  over  the  sternomastoid  muscle 
and  starting  from  the  mastoid  process 
joins  the  short  arm  along  the  clavicle, 
the  dissection  being  carried  from  below 
upward  and  outward  from  the  mesial 
line,  the  external  jugular  vein  being 
tied  with  two  ligatures  and  divided  be- 
tween them.  The  omohyoid  muscle  is 
then  divided,  and  by  using  it  as  .  a 
retractor  the  internal  jugular  vein  is 
exposed  and  the  sternomastoid  muscles 
pulled  aside.  In  dissecting  out  the 
mass  of  glands  the  greatest  difficulty  is 
experienced  with  the  chain  connecting 
the  anterior  and  posterior  triangles 
behind  the  sternomastoid  muscle,  as  the 
spinal  accessory  nerve  passes  through 
the  mass  and  is  generally  very  adherent. 
It  is  only  when  there  is  very  extensive 
mischief  that  it  becomes  necessary  to 
divide  the  sternomastoid  muscle  or 
spinal  accessory  nerve,  or  even  to  tie 
and  divide  the  internal  jugular  vein, 
and  these  steps  should  only  be  resorted 
to  when  the  advantages  of  free  ex- 
posure outweigh  other  considerations. 
The  wound  is  closed  with  a  subcu- 
taneous silver  suture  and  drained  at  its 
most  dependent  part.  The  resulting 
scar  is  usually  sHght. 

When  many  glands  are  involved  and 
suppuration  has  occurred,  or  when  peri- 
adenitis is  present,  excision  is  not  to  be 
recommended,  as  extensive  connective- 
tissue  infiltration  renders  it  impossible 
to  remove  all  the  infected  tissue. 

Subcutaneous  extirpation  may  be 
resorted  to,  but  the  method  allows  of 
l)Ut  imperfect  evacuation  of  the  glan- 
dular contents  and  can  hardly  be 
recommended. 


Drainage  of  the  abscess  is  a  measure 
which  may  be  recommended  for  many 
reasons.  A  small  incision  is  sufficient 
for  all  purposes,  and  there  is  practically 
no  scar  left. 

Mesenteric  tuberculous  glands  should 
be  removed  if  possible.  They  are  usu- 
ally discernible  as  persistent  movable 
tumors  beneath  the  abdominal  wall, 
with  anorexia,  loss  of  weight  and 
strength,  occasional  fever,  colicky  pains, 
and  possibly  mucus  in  tl:e  stools  with  a 
tendency  to  diarrhea. 

Case  in  a  female,  aged  25  years, 
clerk,  who  had  been  complaining  for 
one  and  one-half  years  of  malaise, 
slight  acceleration  of  pulse,  and  rise  cf 
temperature.  She  had  a  movable  tu- 
mor the  size  of  a  hen's  egg,  one  and 
one-half  inches  below  the  umbilicus,  in 
the  middle  line.  The  mass  was  re- 
moved. Intestine  was  resected.  No 
drainage.  Patient  made  a  complete 
recovery.  Collins  (Interstate  Med. 
Jour.,  vol.  xi,  p.  366,   1904). 

Case  of  a  man,  aged  41  years,  who 
had  been  ill  for  six  months.  He  com- 
plained of  urethral  pain  before,  and 
pain  in  the  groins  after,  urination.  The 
tip  of  the  sacrum  was  so  sensitive  that 
he  could  not  sit.  Careful  examination 
was  negative.  Several  months  later  an 
X-ray  picture  showed  a  shadow  op- 
posite the  third  lumbar  vertebra,  which 
might  suggest  renal  calculus.  Explora- 
tory laparotomy  revealed  a  thin,  atrophic 
appendix,  and  in  the  mesentery  opposite 
the  third  lumbar  vertebra  was  found  a 
caseous  and  cretified  gland  the  size  of 
a  large  walnut.  Appendix  was  re- 
moved. The  gland  was  incised,  cu- 
retted, and  obliterated  with  sutures. 
No  drainage  and  no  gut  was  resected. 
Patient  made  a  good  recovery.  He  had 
no  family  or  other  history  of  tubercu- 
losis. E.  M.  Corner  (Lancet,  Dec.  23, 
1905). 

Less  radical  measures  sometimes 
bring  about  a  cure.  A  transformation 
of  the  tuberculous  tissues  into  a  scle- 
rotic mass  may  be  obtained.    A  solution 


Adenitis  (wiTHERSXiNfi). 


387 


of  chloride  of  zinc  injected  about  the 
tul^erculons  foci  excites  a  growth  of 
new  fibrous  tissue,  which  encapsulates 
the  diseased  portion. 

Solutions  of  iodoform  and  ether 
(iodoform,  1  part;  ether,  5  parts;  dis- 
tilled water,  5  parts.  Injection  not  to 
be  repeated  while  iodoform  is  being 
excreted  in  the  urine),  after  A^erneuil, 
in  cases  where  operative  procedures  are 
incHcated,  give  a  lasting  cure,  without  a 
cicatrix.  These  injections  seem  to 
exert  a  beneficial  action  not  only  on 
the  tuberculous  glands  treated,  but  also 
on  those  at  a  distance  from  the  seat  of 
the  injection.  Robin  uses  an  injection, 
iodoform,  1  part ;  ether,  10  parts ;  oil 
of  sweet  almonds,  100  parts ;  creosote, 
2  parts. 

The  connection  between  inflammatory 
conditions  of  the  nasopharyngeal  space 
and  acute  infections  of  the  glands  at 
the  angle  of  the  jaw  should  be  borne 
in  mind.  If  promptly  after  the  lighting 
up  of  the  primary  inflammation  of  the 
gland  as  evidenced  by  its  enlargement, 
further  absorption  of  infectious  mat- 
ter from  the  nasopharynx  can  be  pre- 
vented, the  gland  will  cope  successfully 
with  the  initial  invasion  and  resolution 
occur,  but  if  fresh  invasions  are  allowed 
to  take  place  resistance  will  be  over- 
come and  the  gland  will  break  down. 
Attention  should  therefore  at  once  be 
directed  to  the  problem  of  limiting  sep- 
tic absorption  from  the  nasopharynx  by 
measures  which  keep  the  mucous  mem- 
brane clean  and  also  restore  it  as  soon 
as  possible  to  a  normal  condition. 

Chlorate  of  potash  has  an  almost 
specific  action  in  limiting  the  pharyn- 
geal inflammations  of  childhood,  there- 
fore : — 

^  Potassii  chloratis   gr.  j-ij. 

Sig. :  Every  two  hours  for  twenty- 
four  hours,  then  every  three  hours,  and 
later  every  four  hours. 

To  cleanse  and  soothe  the  naso- 
pharynx some  mild  alkaline  wash  is 
necessary.  Of  value  in  this  connec- 
tion are: — 


IJ  Tablets  alkaline  antiseptic  {Seller'), 

Sig.:  Dissolve  one  in  a  half-glassful 
of  water  and  pour  a  little  with  a  tea- 
spoon into  each  nostril  every  three 
hours. 

The  results  obtained  from  this  line 
of  treatment  were  immediately  most 
gratifying.  T.  S.  South  worth  (Jour. 
Amer.  Med.  Assoc,  May  30,   1903). 

The  following  plan  is  recommended : 
A  salve  composed  of  equal  parts  of 
ichthyol  and  official  ointments  of  io- 
dine, mercury,  and  belladonna,  to  be 
well  rubbed  in  daily,  and  the  bubo 
covered  with  gauze  dressing,  upon 
which  the  same  salve  has  been  spread 
thickly.  It  should  be  held  tightly 
against  the  area  by  spica  bandage.  If 
the  swelling  then  breaks  down,  infil- 
trate the  softest  and  most  prominent 
part  of  the  swelling  with  1  per  cent. 
cocaine;  incise,  empty  out  the  pus 
from  the  cavity  by  pressure,  wash 
out  two  or  three  times  with  hydro- 
gen peroxide,  diluted  one-half  with 
sterile  water,  then  flush  with  sterile 
water  alone,  using  an  ordinary  glass 
syringe.  Melt  some  10  per  cent,  iodo- 
form ointment  and  inject  into  cavity 
with  some  force,  to  fill  it  completely. 
Cover  with  cold  bichloride  gauze  com- 
press, retained  by  spica.  After  five 
days  remove  dressing  and  squeeze 
out  excess  of  ointment,  or  reinject  if 
any  pus  remains.  Royster  (Medical 
Record,  Feb.  25,  1911). 

Camphor-naphthol  has  proved  valu- 
able in  some  cases.  It  is  prepared  as 
follows : — 

IJ  Betanaphthol, 

Camphor    aa  10  parts. 

Alcohol  (60  per  cent.)    40  parts. 

A  few  drops  are  to  be  injected,  with 
antiseptic  precautions,  here  and  there 
throughout  the  mass  of  indurated 
glands,  as  suggested  by  Courtin,  of 
Bordeaux. 

It  is  claimed  in  favor  of  camphor- 
naphthol  that  there  is  no  danger  of 
intoxication  and  that  the  treatment  is, 
almost    painless.      Menard    and    Calot„ 


388 


AGENITIS    (WITHERSTINE). 


however,  have  reported  cases  of  intoxi- 
cation following  injection  of  camphor- 
naphthol  into  abscess  cavities.  The 
patient  suffered  from  frequent,  rapid 
pulse,  loss  of  consciousness,  and  epilep- 
tiform attacks.  The  quantity  of  the 
drug  injected  was  about  6  drams.  This 
patient  recovered.  In  another  case,  8 
years  of  age,  1^  ounces  of  the  solution 
were  injected.  In  the  third  case,  aged 
12,  5  drams.  In  the  last  2  cases  life 
was  saved  by  freely  opening  the  cavity 
and  washing  it  out  on  the  first  appear- 
ance of  toxic  symptoms. 

Camphorated  guaiacol  injected,  4 
minims  into  the  center  of  each  gland, 
causes  a  rapid  diminution  of  size,  and 
ultimate  atrophy.  Glands  which  are 
beginning  to  soften  should  not  be 
treated  after  this  manner.  Absolute 
success  obtained  in  forty-six  glands. 
(  Simon  (Jour,  de  med.,  No.  SO,  1904). 

Interstitial  injections  of  iodine,  fre- 
quently recommended,  usually  fail  or 
cause  suppuration,  owing  to  the  fact 
that  the  tincture  of  iodine  is  employed. 
Metallic  iodine,  however,  gives  good 
results;  the  abscess  is  filled  with  the 
crystalline  iodine,  8  or  10  applications 
usually  insuring  a  cure. 

Barjou,  of  Lyons,  commends  the  use 
of  the  X-ray  in  the  treatment  of  tuber- 
cular adenitis.  The  principal  effect  of 
this  treatment  is  upon  the  general  in- 
filtration which  so  often  accompanies 
scrofula,  uniting  the  lymph-glands  in  a 
solid  mass.  The  glands  become  sep- 
arated soon  after  beginning  the  appli- 
cations, and  later  disappear.  If  there 
is  any  tendency  to  softening,  the  rays 
hasten  this,  so  that  the  abscess  may  be 
opened  earlier.  The  rays  continue  to 
have  a  good  effect  upon  the  suppurat- 
ing tissues.  Untoward  effects  or  tend- 
ency to  cause  metastasis  are  rarely 
noted. 


The  Roentgen-ray  treatment  is  the 
most  effective  method  for  the  treat- 
ment of  tuberculous  adenitis  in  all  its 
varieties.  It  afifords  also  the  best  cos- 
metic, as  well  as  permanent,  results. 
If  treated  early  the  scars  are  com- 
pletely avoided — an  important  consid- 
eration, especially  in  young  women, 
who  are  often  subject  to  the  disease. 
The  treatment  is  harmless  and  pain- 
less, but  must  be  adapted  to  the  indi- 
vidual. If  too  weak  there  will  be  no 
progress,  and  if  pushed  too  far  it 
may  be  hurtful.  It  seems  also  to 
raise  the  opsonic  index  and  to  pro- 
duce autogenous  vaccines  or  anti- 
bodies, which  pass  through  the  pa- 
tient's system  and  effect  tuberculous 
lesions  at  a  distance  and  produce  an 
immunity.  The  treatment  is  not  con- 
fined to  the  earlier  stages,  though  it 
is  in  these  that  the  best  cosmetic  re- 
sults are  obtained.  C.  L.  Leonard 
(Jour.  Amer.  Med.  Assoc,  May  14, 
1910). 

Koch's  tuberculin  and  the  simultane- 
ous use  of  the  Bier  method  have 
been  used  with  success  in  tuberculous 
adenitis. 

After  treatment  of  tuberculous  ade- 
nitis and  other  non-pulmonary  tuber- 
culous lesions  by  the  injection  of  Koch's 
old  tuberculin,  the  glands  were  reduced 
in  size,  discharging  sinuses  healed,  and 
there  was  neither  spread  nor  recurrence 
of  the  disease.  The  writer  reports  10 
cases  of  adenitis,  4  of  tuberculous 
otitis  media,  3  of  deposits  in  the  phar- 
ynx, 4  of  tuberculosis  of  the  bladder, 
3  of  joint  tuberculosis,  and  1  of  tuber- 
culous testicle.  In  the  joint  cases  Bier's 
hyperemia  was  added  to  the  tuberculin 
treatment.  Tuberculin  stimulates  the 
production  of  tuberculo-opsonins,  and 
causes  a  hyperemia  around  the  tuber- 
culous area,  thus  aiding  in  the  process 
of  inoculation.  G.  R.  Pogue  (Med. 
Rec,  Aug.  29,  1908). 

C  Sumner  Witherstine, 

Philadelphia. 


ADENOID    VEGETATIONS    (KNIGHT). 


389 


ADENOID  VEGETATIONS — 

DEFINITION.— A  definition  of  ade- 
noid vegetations,  or  adenoids,  must  be 
somewhat  elastic.  The  name  tonsil  is 
often  appHecl,  and  we  hear  pharyngeal 
tonsil,  third  tonsil,  Luschka's  tonsil,  or 
bursa,  used  indiscriminately.  It  would 
be  well  to  restrict  the  term  tonsil  to  the 
lymphoid  aggregation  between  the  pil- 
lars of  the  fauces,  where  it  was  fiirst 
employed.  The  word  adenoid  seems  to 
have  been  proposed  nearly  two  thous- 
and years  ago  (Wright,  "The  Nose  and 
Throat  in  the  History  of  Medicine"), 
is  therefore  sanctified  by  time  and  us- 
age, and  will  doubtless  be  permanently 
retained. 

Lymphoid  tissue  is  a  normal  con- 
stituent of  mucous  membranes,  but  the 
question :  When  does  it  become  patho- 
logical? is  not  easy  to  answer.  On  the 
one  hand  we  are  told  that  it  is  abnormal 
"when  visible  to  the  naked  eye,"  and 
on  the  other  "when  it  causes  subjective 
symptoms."  Many  insignificant  hyper- 
plasise  cause  a  good  deal  of  disturb- 
ance, and  on  the  contrary  in  a  stolid, 
phlegmatic  child  or  in  a  pharynx  of 
large  dimensions  very  considerable 
hypertrophies  often  seem  to  interfere 
but  little  with  comfort  or  health.  An 
accurate  definition  is  desirable,  but  in 
view  of  the  fact  that  lymphoid  tissue 
is  a  recognized  avenue  for  invasion  of 
the  system  by  pathogenic  germs  it  is 
most  important  to  determine  in  what 
condition  of  this  tissue,  healthy  or  dis- 
eased, the  process  of  invasion  is 
favored.  Clinically  it  is  clear  that, 
when  diseased,  it  is  no  longer  capable 
of  performing  its  physiological  function 
and  is  a  detriment  to  health  quite  apart 
from  effects  due  merely  to  mechanical 
obstruction.  The  general  symptoms 
present  can  hardly  be  explained  on  the 
latter    ground    alone,      A    species    of 


toxemia  must  be  also  concerned.  Dis- 
tended crypts  provide  an  excellent  bed 
for  the  cultivation  of  germs,  which  find 
ready  access  to  the  circulation  in  the 
absence  of  efifecti  resistance.  Lym- 
phoid tissue  may  be  a  portal  of  entry 
without  itself  showing  marked  patho- 
logical change,  while  it  is  probable  that 
a  dense  fibrous  adenoid,  as  met  with  in 
older  subjects,  may  ofTer  a  firm  barrier 
to  bacterial  assaults. 

SYMPTOMS  AND  DIAGNOSIS. 
■ — It  is  not  safe  to  rely  upon  the  so- 
called  "adenoid  facies"  as  a  diagnostic 
sign.  A  very  similar  appearance  is 
sometimes  seen  in  a  subject  of  intra- 
nasal obstruction,  while  the  postnasal 
space  is  quite  free.  A  typical  case  of 
adenoid  hypertrophy  in  the  vault  of  the 
pharynx  usually  wears  a  dull,  Hstless 
expression.  The  nostrils  are  narrow 
and  pinched ;  the  bridge  of  the  nose  by 
contrast  seems  widened.  The  upper  lip 
is  retracted,  exposing  the  teeth  of  the 
upper  jaw,  which  project  and  overlap 
those  of  the  lower.  The  upper  jaw  is 
compressed  laterally,  so  that  the  roof 
of  the  mouth  is  converted  into  a  Gothic 
or  V-shaped  arch.  Deflection  of  the 
nasal  septum  may  be  a  result.  The 
nasolabial  folds  are  effaced,  and  the 
transverse  vein  at  the  root  of  the 
nose  is  unusually  conspicuous  (Scanes 
Spicer).  The  child  has  a  pasty,  sallow 
complexion,  and  the  cervical  glands  are 
prominent.  The  nutrition  of  a  nursing 
infant  suffers  in  consequence  of  fre- 
quent interruptions  due  to  need  of  get- 
ting air  through  the  mouth.  For  a 
similar  reason  older  children  "bolt" 
their  food,  which  being  defectively  in- 
salivated causes  gastric  derangement. 
The  latter  is  further  aggravated  by 
catarrhal  secretion,  always  in  excess 
in  these  cases,  finding  its  way  into 
the    stomach.      Loss    of    appetite    and 


390 


ADENOID    VEGETATIONS    (KNIGHT). 


malassimilation  are  natural  sequels. 
In  severe  cases  deformity  of  the 
chest,  pigeon-breast  (Dupuytren),  re- 
sults from  the  bad  constitutional  state, 
the  labored  breathing,  or  from  both 
combined.  The  mental  dullness  shown 
by  these  children  is  referred  to  inter- 
ference with  the  lymphatic  drainage  of 
the  brain  and  to  impaired  hearing. 

Investigations  in  1573  German  school 
children.  Of  this  number  315,  or  about 
18  per  cent.,  were  found  to  have  a  suf- 
ficient degree  of  impairment  of  hearing 
to  make  a  professional  examination 
advisable,  although  in  the  majority  of 
them  the  impairment  had  not  been  no- 
ticed, either  by  the  patients  themselves 
or  by  the  teachers.  In  153  cases  the 
impairment  of  hearing  was  directly 
referable  to  the  presence  of  adenoids, 
and  in  12  additional  cases  it  was  refer- 
able to  the  consecutive  changes  induced 
by  adenoids  which  had  spontaneously 
resolved.  The  number  of  cases  in 
which  adenoid  vegetations  could  be  re- 
garded as  the  causative  factor  in  the 
impairment  of  hearing  in  all  the  cases 
considered  amounted  therefore  to  about 
52  per  cent.,  and  the  author  lays  stress 
upon  the  importance  of  a  preliminary 
examination  of  all  school  children,  both 
objectively  and  by  hearing  tests,  at 
their  entrance  upon  school  life,  as  well 
as  at  later  stated  intervals,  and  gives 
the  Bezold  estimate  of  2  meters,  for  the 
whispered  voice,  as  the  lowest  accept- 
able standard.  Cohn  (Zeit.  f.  Ohren- 
heilkunde,  Bd.  Hi,  S.  246,  1906). 

An  investigation  of  the  occurrence 
of  adenoids  in  three  London  elemen- 
tary schools,  with  an  attendance  of 
2315,  showed  that,  on  the  average, 
about  37  per  cent,  of  the  children  in 
elementary  schools  have  adenoids, 
and  that  between  72  and  Id  per  cent, 
of  these  have  enlarged  tonsils  as  well. 
On  the  average,  31.2  per  cent,  of  ade- 
noid cases  are  mouth-breathers,  com- 
plete or  partial,  and  hypertrophy 
of  the  faucial  tonsils  may  give  rise 
to  mouth-breathing  in  the  absence  of 
adenoids.  Sex  appears  to  have  no  in- 
fluence   upon    the    incidence    of    ade- 


noids. Adenoids  are  more  common 
about  the  age  of  8  years,  and  are  next 
most  frequent  at  about  12  years.  True 
aprosexia  is  often  confused  with  ap- 
parent dullness,  due  to  defective  hear- 
ing, and  it  occurs  in  only  about  4.7 
per  cent,  of  adenoid  cases,  is  more  fre- 
quent in  girls,  and,  when  present,  is 
associated  with  a  marked  degree  of 
adenoids.  Macleod  Yearsley  (Brit. 
Jour.  Child.  Dis.,  Feb.,  Mar.,  1910). 

During  the  last  year  there  have 
appeared  at  the  Eye  and  Ear  Infirm- 
ary in  Newark  471  cases  of  adenoids, 
all  but  166  of  which  were  associated 
with  operations  on  the  tonsils.  The 
writer  draws  the  following  conclu- 
sions: 1.  The  condition  of  inatten- 
tion and  lack  of  power  of  concentra- 
tion is  frequently  seen  in  juvenile 
mouth-breathers,  and  they  are  uni- 
formly helped  by  operation.  The  ef- 
fect is  immediate  and  striking.  2. 
In  those  young  children  having  the 
lymphatic  tendency  and  bearing  stig- 
mata of  degeneracy,  the  enucleation 
of  the  tonsils  and  the  removal  of  ade- 
noids are  followed  by  most  brilliant 
results.  3.  The  conditions  called 
choreal,  due,  as  they  frequently  are, 
to  peripheral  irritation,  are  not  only 
greatly  helped,  but  frequently  perma- 
nently cured  by  the  removal  of  the 
peripheral  irritation.  4.  In  the  con- 
genital defects  of  mental  development 
the  mental  deficiency  is  bettered  by 
the  removal  of  the  handicap  to  the 
general  development.  5.  He  has 
seen  a  typical  case  of  mental  defi- 
ciency of  the  Mongolian  type  which 
showed  a  marked  improvement  fol- 
lowing the  operation  for  the  removal 
of  adenoids.  W.  P.  Eagleton  (Medi- 
cal Record,  July  30,  1910). 

The  term  aprosexia  has  been  given  to 
lack  of  ability  to  concentrate  (Guye). 
Mouth-breathing  is  a  source  of  much 
discomfort  and  even  danger.  The 
membranes  of  the  whole  respiratory 
tract  suffer  from  inhalation  of  improp- 
erly prepared  air. 

Two  facts  are  beyond  dispute :  The 
peculiar    susceptibility    in    childhood   to 


ADENOID    VEGETATIONS    (KNIGHT). 


391 


infectious  diseases,  and  the  mode  of  in- 
vasion is  by  the  upper  respiratory  tract. 
As    corollary    to    these,    the    following 
conclusions    are    submitted :     The    pha- 
ryngeal tonsil  possesses  a  distinct  func- 
tion or  functions.     This  function  is  of 
the    nature    of    a    defense    against    the 
entrance  of  bacteria,  and  consists  in  a 
certain  irrigation  of  the  tonsil  surface 
by  a  lymph-stream  loaded  with  lympho- 
cytes.    This  protection  function  carries 
with    it    the    inherent    qualities    of    the 
tonsil   to   enlarge   on  the   slightest   irri- 
tation    for    the    affording    of     further 
power  of  defense.     This  inherent  tend- 
ency  of   the   tonsil   to    enlarge   is    fur- 
ther   seen    in    the    frequent    recurrence 
of   the    tonsil    after    removal.      Strictly 
speaking,    then,    in    the    great    majority 
of   cases   such   enlargements   are   not   a 
pathological,      but      a     physiological, 
process.    Harris  (American  Medicine, 
Jan.  2,  p.  20,  1904). 
Snuffling  and  noisy  breathing  by  day 
and  snoring  at  night  are  often  distress- 
ing.    Sleep  is  much  disturbed  thereby 
as  well  as  by  bad  dreams,  "night  ter- 
rors" {pavor  nocturnus)  resulting  from 
deranged  cerebral  circulation.     The  ef- 
fect  upon   the   voice    is    characteristic. 
Its  non-resonant,  "dead"  quality  always 
suggests  adenoids,  at  least  in  young  sub- 
jects.   The  ability  to  precisely  locate  an 
obstruction    from    the    sound    of    the 
voice,   claimed   by   some,    seems   to   be 
hardly     warranted.       In     addition     to 
special    difficulty    with    the    nasal    con- 
sonants speech  in  general  is  thick  and 
unpleasing.      Actual    stammering    and 
stuttering  have  been   ascribed   to  ade- 
noids, and  a  long  list  of  reflex  neuroses 
affecting  the  eyes,  the  ears,  and  more 
remote     organs     has     been     compiled. 
Among  them  may  be  mentioned  laryn- 
geal  spasm,   hiccough,   asthma,   hernia, 
prolapse     of     the     rectum,     nocturnal 
enuresis,  chorea,  and  epilepsy,  some  of 
which  no  doubt  have  their  origin  in  the 
imagination  of  the  observer.     The  rela- 
tion of  laryngeal  neoplasms  to  adenoids 


is  a  question  of  much  interest.  Even  if 
we  decline  to  accept  a  theory  of  "ver- 
rucous diathesis,"  or  special  predisposi- 
tion to  neoplastic  development,  it  is 
reasonable  to  assume  that  habitual 
mouth-breathing  must  irritate  the  laryn- 
geal mucosa.  It  has  also  been  sug- 
gested that  secretions  find  their  way 
from  above  into  the  vestibule  of  the 
larynx,  and,  again,  that  the  extraordi- 
nary labor  imposed  upon  the  larynx 
during  phonation  under  these  circum- 
stances favors  the  formation  of  new 
growths.  In  spite  of  what  might  be 
expected,  some  excellent  observers 
maintain  that  neoplasms  of  the  larynx 
are  not  especially  common  in  adenoid 
•  cases.  Frequent  attacks  of  earache,  of 
nosebleed,  and  a  tendency  to  catch  cold, 
are  generally  included  in  the  list  of 
symptoms.  Headache  and  asthenopia 
are  complained  of,  the  senses  of  smell 
and  of  taste  are  impaired,  and  fre- 
quently an  ichorous  discharge  excoriates 
the  nostrils  and  upper  lip. 

The  eyes  are  often  found  to  be  af- 
fected in  cases  of  adenoids,  the  dis- 
eases of  the  eye  usually  found  being : 
1.  Phlyctenular  conjunctivitis  (by  far 
the  most  common).  2.  So-called  weak 
ulcer  of  the  cornea,  the  non-inflamma- 
tory tilcer  which  looks  as  if  a  small 
piece  of-  the  corneal  surface  had  been 
gouged  out ;  sometimes  difficult  to  see 
unless  fuchsin  is  used.  3.  Eczematous 
keratitis,  often  called  phlyctenular  kera-  ' 
toconjunctivitis.  4.  A  peculiar  irrita- 
bility or  hypersensitiveness  of  the  ret- 
ina, leading  to  difficulty  in  opening  the 
eyes  in  a  bright  light.  There  can  be 
no  reasonable  doubt  that  these  oph- 
thalmic conditions  are  secondary  to  the 
nasopharyngeal :  (a)  By  the  marked 
lowering  of  the  general  health  pro- 
duced. .(&)  By  the  actual  extension  of 
the  inflammatory  process  up  the  nasal 
duct  to  the  eye.  Hern  (Brit.  Med. 
Jour.,  Aug.  26,  p.  437,  1905). 

The   writer   agrees   with   Bamberger, 
Moebius,   and  other  authors  in  believ- 


392 


ADENOID    VEGETATIONS    (KNIGHT). 


ing  that  exophthalmos  alone,  if  not 
due  to  mechanical  causes,  is  sufficient 
ground  for  making  the  diagnosis  of 
Basedow's  disease.  He  describes  two 
cases  of  exophthalmos  which  were  com- 
pletely relieved  by  removal  of  adenoid 
vegetations.  The  first  case  was  that 
of  a  boy  of  seven  years,  with  well- 
marked  exophthalmos,  accompanied  by 
both  Graefe's  and  Stellwag's  signs,  and 


ophthalmos,  but  a  week  later  the  ade- 
noids were  removed,  and  in  the  course 
of  the  next  two  weeks  the  exophthal- 
mos disappeared  completely.  The  au- 
thor is  of  the  opinion  that  Basedow's 
disease  represents  an  intoxication  of 
the  central  nervous  system  through 
abnormal  internal  secretions,  and  that 
adenoid  vegetations  are  capable  of 
evoking    the     malady.       Epilepsy     and 


Posterior  rhinoscopic  view.    (After  Grunwald.) 


who  further  presented  the  clinical  pic- 
ture typical  of  adenoids.  Ten  days 
after  removal  of  the  pharyngeal  tonsil 
the  exophthalmos  had  completely  dis- 
appeared. Two  years  later  the  patient 
reappeared  with  a  return  of  all  his 
symptoms,  as  a  recurrence  of  the  ade- 
noids was  again  accompanied  by  bilat- 
eral exophthalmos.  Radical  extirpation 
of  the  vegetations  was  followed  by  per- 
manent cure  of  the  ocular  protrusion. 

The  second  patient  was  also  a  boy  of 
the  same  age,  who,  in  addition  to  ade- 
noids and  exophthalmos,  suffered  from 
hypertrophy  of  the  tonsils.  Amputa- 
tion of  the  latter  structures  was  not 
followed    by    improvement    in    the    ex- 


chorea  probably  have  some  etiological 
similarity  to  Basedow's  disease,  and  the 
author  thinks  that  they  also  may  be 
produced  by  the  presence  of  adenoids. 
An  illustrative  case  is  cited  in  which 
clearing  of  the  nasopharyngeal  space 
in  a  boy  of  7  years  was  followed  by 
the  cure  of  a  well-marked  chorea 
minor.  It  therefore  appears  advisable 
to  look  for  adenoids  in  all  cases  of 
these  three  diseases,  and  to  remove 
them,  even  if  there  is  no  respiratory 
obstruction.  B.  Holz  (Berl.  klin. 
Woch.,  Jan.  23,  p.  91,  1905). 

In  a  large  number  of  school  chil- 
dren who  suffered  with  blurring  vi- 
sion and  fatigue  on  reading,  the  author 


ADENOID    VEGETATIONS    (KNIGHT). 


393 


found  nasopharyngeal  hj-pertrophy 
to  be  the  real  cause  of  the  symptoms. 
Removal  of  the  adenoids  and  correc- 
tion of  faulty  nasal  passages  resulted 
in  cure  in  cases  where,  ordinarily, 
glasses  would  be  thought  necessary. 
W.  M.  Killen  (Brit.  Med.  Jour.,  Sept. 
25,  1909). 

The  picttire  in  the  rhinoscopic  mirror 
is  unmistakable,  Lobulated  or  fissured 
masses  of  various  sizes  are  seen  hang- 
ing from  the  vault  of  the  pharynx, 
obscuring  the  arches  of  the  choanse, 
and  often  filling  the  fossae  of  Rosen- 
miiller  and  covering  the  orifices  of  the 
Eustachian  tubes.  They  have  been 
likened  in  appearance  to  a  "cock's 
comb"  (Czermak,  1860),  and  they  are 
spoken  of  by  Voltolini  (1865)  as 
"stalactite-like  growths,"  a  term  adopted 
by  Morell  Mackenzie.  They  are  often 
visible  by  anterior  rhinoscopy  when 
the  intranasal  structures  have  been 
shrunken  by  atrophy  or  retracted  by 
cocaine.  Sometimes  the  vegetations 
are  distributed  down  the  posterior 
wall  of  the  pharynx,  below  the 
plane  of  the  velum,  or  they  may  push 
forward  into  the  nasal  chambers.  The 
view  may  be  masked  by  viscid  or  in- 
spissated secretion,  and,  being  fore- 
shortened in  the  mirror,  does  not  give 
an  adequate  idea  of  the  volume  of  the 
growth.  In  some  cases,  generally  in 
older  subjects,  the  mass  is  more  uni- 
form and  cushion-like  in  appearance, 
or  is  bilobed,  being  divided  by  an 
anteroposterior  median  furrow  {reces- 
sus  pharyngeus  niedhis),  and  is  less 
vascular  looking.  In  adults  remnants 
of  adenoids  are  often  seen  in  the  form 
of  bands  between  the  Eustachian 
cushion  and  the  pharyngeal  wall,  which 
doubtless  bear  some  relation  to  various 
subjective  aural  disturbances. 

Applications  of  cocaine  and  the  use 
of  a  palate  retractor  are  to  be  recom- 


mended only  in  older  children  and 
when  a  rhinoscopic  examination  is 
iniperative.  By  the  exercise  of  tact  and 
patience  it  is  often  possible  to  get  a 
view,  even  in  a  very  unpromising  case. 
In  some  it  is  out  of  the  question  and 
the  only  resource  is  a  digital  examina- 
tion. The  process  is  disagreeable  to  the 
patient  and  dangerous  for  the  examiner 
in  children,  unless  one's  finger  is  pro- 
tected in  some  way.  A  finger  shield  of 
metal  or  rubber  may  be  used,  or  a 
mouth-gag    may    be    applied.      Better 


Adenoids  seen  through  anterior  nares. 
(After  GriXnwald.) 


Still,  the  child  being  firmly  held  by  an 
assistant,  the  examiner  standing  on  the 
left  presses  the  right  cheek  of  the 
patient  between  the  separated  jaws  with 
his  right  middle  finger  while  he  quickly 
passes  his  left  forefinger  into  the  open 
mouth  and  up  behind  the  velum.  The 
mouth  cannot  be  closed  and  thus  the 
finger  is  safe. 

The  anatomical  landmarks  to  be 
sought  are  the  posterior  margin  of  the 
vomer  in  the  middle  line  and  the  Eu- 
stachian eminences  at  the  sides.  A 
novice  might  mistake  a  prominent 
Eustachian  cushion,  a  papillated  pos- 
terior end  of  an  inferior  turbinate,  or 
even  the  contracted  velum  (F.  H. 
Hooper)  for  an  adenoid  mass,  but  the 


394 


ADENOID    VEGETATIONS    (KNIGHT). 


last  is  higher  in  the  fornix  of  the 
pharynx  and  more  posterior  and  has 
a  distinctly  lobulated,  elastic,  and  pulpy 
feeling,  compared  to  that  of  a  bunch  of 
earthworms.  On  withdrawal  the  fin- 
ger is  smeared  with  blood,  which  is  not 
the  case  when  a  healthy  pharynx  is  ex- 
plored, unless  excessive  force  has  been 
exercised.  In  those  who  object  to  the 
finger  some  idea  of  the  extent  and  con- 
sistence of  a  postnasal  growth  may  be 
gained  by  palpation  with  a  stifif  probe 
or  the  edge  of  a  rhinoscopic  mirror. 
In  some  cases  a  very  beautiful  view  of 
the  vault  of  the  pharynx  is  given  by  the 
ingenious  electric  pharyngoscope  de- 
vised by  Hays.  The  end  of  the  instru- 
ment having  been  passed  into  the  oro- 
pharynx the  patient  is  instructed  to 
close  the  lips  and  breathe  quietly 
through  the  nose.  The  palatal  muscles 
relax  and  permit  the  light  to  flood  the 
cavity  of  the  rhinopharynx.  With  a 
little  patience  and  care  a  complete 
picture  may  be  obtained,  even  in  very 
sensitive  throats.  Nasal  polypi,  retro- 
pharyngeal abscesses,  syphiloma,  and 
neoplasms,  benign  or  malignant,  may 
occur  in  this  region,  but  usually  present 
features  or  give  a  history  which  serve 
to  distinguish  them. 

Benign  nasopharyngeal  polypi,  stud- 
ied in  22  cases.  They  are  usually  uni- 
lateral and  solitary,  and  have  a  peculiar 
pear-shaped  form,  the  broad  end  lying 
in  the  nasopharynx,  while  the  stalk  ex- 
tends into  the  nose.  They  may  attain 
considerable  size,  and  are  subject  to  in- 
flammatory changes  which  may  end  in 
partial  or  total  gangrene.  The  treat- 
ment is  very  favorable,  as  they  are 
easily  laid  hold  of,  and  readily  torn  out 
on  account  of  their  slender  stalk.  In 
the  majority  of  cases  the  polypi  do  not 
recur. 

There  is  usually  a  profuse  dis- 
charge of  serous  fluid  after  the  extrac- 
tion, and  examination  of  the  antrum 
shows    a    slight    chronic    inflammation. 


Choanal  polypi  originate  within  the 
antrum  of  Highmore,  and  are  due  to 
inflammation  of  the  antral  mucous 
membrane.  Killian  (Lancet,  July  14, 
p.  81,  1906). 
It  is  hard  to  believe  that  a  simple 
pendulous  polypus  of  the  nasopharynx 
could  be  mistaken  for  a  bunch  of  ade- 
noids. Yet  the  risk  is  evidently  present 
in  the  minds  of  some  observers.  In 
a  recent  paper  by  W.  A.  Wells  (Laryn- 
goscope, July,  1911)  the  fact  is  noted 
that  it  is  usually  taken  for  granted 
that  postnasal  obstruction  in  a  child 
under  15  years  is  due  to  adenoids.  He 
describes  3  cases  of  fibrous  pol3'pus, 
which  he  makes  the  basis  of  a  plea  for 
intranasal  removal  with  the  cold-wire 
snare  rather  than  by'  a  "mutilating" 
external  operation  generally  employed 
in  growths  of  this  kind.  He  enumer- 
ates three  theories  of  etiology:  (1) 
cranial,  propounded  by  Nelaton;  (2) 
choanal,  that  is,  springing  from  the 
ethmoid,  sphenoid,  or  vomeral  region, 
and  (3)  sinusal,  as  adopted  by  Killian 
in  the  paper  above  quoted.  While  it 
is  well  to  bear  them  in  mind,  fibrous 
polypi  of  the  pharynx  are  so  rare  and 
their  symptoms  are  so  different  from 
those  of  adenoids,  except  in  the  single 
feature  of  obstruction,  that  the  chance 
of  confusion  is  rather  remote. 

Rugae  or  folds  of  thickened  mucous 
membrane  in  the  floor  of  the  nose,  and 
the  so-called  "lateral  bands"  of  red  and 
thickened  membrane  on  the  walls  of 
the  pharynx  behind  the  posterior  pillars 
{pharyngitis  lateralis  hypertropica) 
are  regarded  by  some  as  pathogno- 
monic, but  each  is  often  found  without 
adenoids.  Fluid  injected  into  one  nos- 
tril is  expected  to  escape  by  the  other 
if  the  nasopharynx  is  free;  by  the 
mouth  if  adenoids  are  present  (Semon, 
quoted  by  Schech).  A  similar  test  with 
oil  spray  is  regarded  as  "almost  abso- 


AbENOID    VEGETATIONS    (KNIGHT). 


395 


hitely  diagnostic"  (Bosworth).  Each 
of  these  experiments  must  be  invaH- 
dated  by  a  unilateral  nasal  stenosis  and 
should  not  be  relied  upon. 

Adenoids  may  exist  without  enlarged 
f  aucial  tonsils :  the  reverse  is  seldom 
true.  Hence  it  is  important  to  examine 
the  pharyngeal  vault  in  all  who  mani- 
fest the  latter  condition.  The  occur- 
rence of  adenoids,  as  well  as  of  tur- 
binate hypertrophy,  in  victims  of  cleft 
palate  has  often  been  remarked, 
whether  as  an  effort  of  nature  to  stop 
the  gap  or  as  a  consequence  of  the 
same  diathesis  that  caused  the  palatal 
deformity  is  hard  to  decide.  Such  cases 
afford  unusual  opportunity  for  study  of 
these  anomalies. 

ETIOLOGY. — A  constitutional  state 
allied  to  struma,  termed  lymphatism 
(Potain),  predisposes  to  lymphoid  hy- 
perplasia. From  observation  of  1995 
cases  Sendziak  concludes  that  "scrof- 
ula" plays  an  important  part  in  etiology, 
a  view  shared  by  Lennox  Browne. 
The  exanthemata,  syphilis,  tuberculosis, 
are  similarly  accused.  Poor  sanitation, 
bad  hygiene,  and  improper  diet  are 
undoubted  factors,  yet  not  infrequently 
cases  occur  in  which  none  of  the  fore- 
going elements  is  concerned  and  we  are 
at  a  loss  to  discover  the  cause  of  the 
condition. 

The  importance  of  nasal  stenosis, 
resulting  perhaps  from  some  injury  in 
early  life,  is  generally  admitted.  Be- 
hind an  obstruction  the  air  is  so  rarefied 
on  inspiration  that  congestion  of  the 
mucous  membrane  results  with  conse- 
quent tendency  to  hyperplasia.  The 
bearing  of  this  fact  with  reference  to 
treatment  should  be  appreciated.  The 
habitual  breathing  of  impure  air,  or  of 
air  too  hot  or  dry,  often  prevailing  in 
our  homes  and  sleeping  rooms,  no 
doubt  has  a  bad  effect  on  the  mucous 


membranes.  The  same  is  true  of  cer- 
tain occupations  that  involve  the  inhala- 
tion of  irritating  vapors  or  floating 
matter  in  the  air.  The  condition  occurs 
with  equal  frequency  in  the  two  sexes. 
It  seems  reasonable  to  admit  an  in- 
herited proclivity.  Those  who  deny  the 
existence  of  heredity  find  it  difficult  to 
explain  the  exhibition  of  almost  iden- 
tical local  conditions  in  several  suc- 
cessive generations.  The  effect  of  a 
rigorous  climate  is  not  necessarily  bad, 
but  extremes  and  sudden  changes  of 
temperature  and  humidity  are  no  doubt 
harmful. 

Adenoid  growths  are  essentially  a 
disease  of  early  life,  of  the  formative 
period,  when  the  lymphoid  tissues  are 
especially  active.  A  few  congenital 
cases  are  on  record.  Among  437  chil- 
dren in  the  first  three  years  of  life 
examined  by  W.  F.  Chappell  not  a 
single  example  of  lymphoid  hypertrophy 
under  the  age  of  three  months  was 
found. 

Some  instances  of  adenoid  vegeta- 
tions in  infancy  appear  to  be  truly- 
congenital,  symptoms  referable  to  the 
condition  being  present  at  birth.  A 
considerable  number  of  infants  suffer 
from  slight  degree  of  adenoid  vegeta- 
tions, as  evidenced  by  mild  symptoms 
of  nasal  obstruction  and  catarrh.  But 
there  are  also  not  a  few  cases  in 
which  more  severe  and  even  grave 
symptoms  may  be  present.  These  will 
materially  interfere  with  the  health  of 
the  infant,  and  do  not  tend-  to  im- 
prove with  ordinary  medical  treatment. 
There  are  several  forms  of  the  affec- 
tion :  the  first,  in  which  there  are 
marked  nasal  obstruction  and  catarrh, 
with  or  without  epistaxis ;  the  second, 
in  which  reflex  phenomena  are  the 
principal  manifestations  of  the  trouble, 
without  any  real  nasal  obstruction 
(such  signs  may  be  convulsions,  laryn- 
geal stridor,  and  vomiting)  ;  the  third, 
those  in  which  secondary  septic  affec- 
tions  predominate,    these   being   chiefly 


396 


ADEXOID    VEGETATIOXS    (KXIGHT). 


septic  adenitis  and  otitis  media,  and, 
lastly,  those  cases  in  which  nasal  ob- 
struction is  present  and  is  associated 
with  nervous  and  septic  conditions.  In 
by  far  the  larger  number  of  cases  of 
adenoids  in  infanc}',  the  S3'mptoms  are 
slight  and  do  not  call  for  active  opera- 
tive treatment,  but,  on  the  other  hand, 
there  are  certainly  some  cases,  com- 
paratively few  in  number,  in  which  the 
signs  and  symptoms  are  such  as  to  de- 
mand removal  of  the  adenoid  growth. 
In  these  the  improvement  that  follows 
operation  tends  to  confirm  the  fact  that 
the  various  phenomena  that  the  infant 
presents  are,  in  reality,  due  to  the 
lesion  in  the  nasopharynx.  R.  C.  Dun 
(Lancet,  August  15,  p.  474,  1903). 

Adenoid  vegetations  are  present  in 
nursing  children  more  frequently  than 
is  usually  supposed.  The  symptoms  are 
difficult  and  noisy  nasal  respiration,  and 
there  is  usually  some  nasal  secretion. 
In  advanced  cases  there  is  marked 
dyspnea,  laryngeal  spasms,  disturbed 
sleep,  and  restlessness  during  waking 
hours.  The  nutrition  is  diminished,  the 
skin  pale,  and  the  cries  are  weak  and 
changed  in  their  timbre.  The  first  de- 
velopment of  these  cases  is  hard  to 
establish  because  it  is  exceptional  that 
a  specialist  is  consulted,  and  frequently 
the  little  patient  succumbs  to  a  pro- 
gressive inanition;  if  it  survives,  it 
grows  with  the  characteristics  of  ade- 
noidism. 

If,  on  the  other  hand,  the  proper 
treatment  is  followed,  the  trans- 
formation is  complete ;  the  mechanical 
difficulty  of  respiration  ceases,  the  nu- 
trition improves,  the  child  gains  rapidly 
in  weight,  and  recovers  its  normal 
quietness  and  sleep.  F.  Massei  (Revue 
Hebd.  de  Laryn.,  etc.,  Oct.  22,  p.  499, 
1904). 

Very  little  consideration  is  usually 
given  to  the  presence  of  adenoids  in 
the  infant,  although  they  are  common 
and  their  evil  results  even  greater 
than  in  childhood.  The  anatomical 
construction  of  the  pharynx  and  post- 
nasal space  in  infants  makes  a  small 
amount  of  adenoid  tissue  a  marked  im- 
pediment to  respiration.  They  are 
directly  responsible    for  the  attacks  of 


otitis  media  so  often  seen  in  infants. 
J.  L.  Morse  (Jour.  Amer.  Med.  Assoc, 
Xov.  9,  p.  1589,  1907). 

The  writer  criticises  the  neglect  of 
adenoids  in  early  infancy,  as  they  in- 
terfere with  the  proper  development 
of  the  child  by  reflex  action,  by  the 
irritation  they  produce  and  the  ob- 
struction they  cause.  The  postnasal 
pharynx  at  birth  is  a  space  only  one- 
quarter  inch  high  by  one-third  inch 
wide,  so  that  a  very  slight  adenoid 
hypertrophy  at  this  period  will  cause 
obstruction.  At  the  end  of  the  first 
year  it  is  nearly  doubled  in  size.  It 
often  produces  symptoms  in  the  first 
days  of  life,  and  the  mistake  is  some- 
times made  of  diagnosing  specific  dis- 
ease. The  snuffles  are  specially 
marked  while  the  child  is  nursing  and 
result  from  an  adenoid  which  pro- 
duces irritation,  and,  if  large  enough 
to  obstruct  the  pharynx,  there  is 
mouth-breathing.  Other  causes  may 
produce  mouth-breathing,  but  ade- 
noids do  so  most  frequently  during 
the  first  year  of  life.  A  third  indica- 
tion of  the  condition  is  the  appear- 
ance of  recurrent  colds,  which,  during 
the  first  year,  are  usually  caused  by 
adenoids.  Another  most  characteristic 
sign  is  a  persistent  cough,  sometimes 
simulating  w^hooping-cough,  without 
any  other  indication  in  the  pharjmx 
or  bronchi  to  account  for  it.  A  fifth 
and  most  dangerous  condition  is  oti- 
tis media.  It  is  not  always  easy  in  a 
very  young  infant  to  determine  the 
presence  of  adenoids,  but  it  can  be 
done  by  rapid  manipulation.  The 
right  index  finger  being  rapidly 
passed  into  the  mouth  while  the  jaw 
is  held  open  by  the  ends  of  the  fingers 
of  the  left  hand  pressing  on  the  teeth, 
the  rough  surface  of  the  adenoid  can 
be  detected  by  the  skilled  physician 
and  sometimes  so  quickly  that  the 
baby  does  not  even  cry.  R.  G.  Free- 
man (Jour.  Amer.  Med.  Assoc,  Aug. 
21, 1909). 

From  a  study  of  32  cases  Erdely  con- 
cludes that  adenoids  are  congenital  and 
should  be  removed  in  children  after  the 
sixth  month  if  symptoms  are  present. 
(Jahrb.  der  Kinderh.,  May,  1911.) 


ADENOID    VEGETATIONS    (KNIGHT). 


397 


Rare   instances   have   been   noted   in 
the  aged,  but  the  tendency  is  toward 
atrophy  after  puberty.     Several  cases 
in  elderly  people  have  been  observed  by 
Bryson  Delavan,  who  holds  the  behef 
that  the  condition  may  develop  in  mid- 
dle life  and  is  not  necessarily  a  legacy 
from  childhood.     One  was  discovered 
by  J.   Solis-Cohen  in  a  woman  of  70, 
and  a  number  of  authentic  cases  after 
the  age  of  60  have  been  reported  (P.  G. 
Frank),    but    at    this    time    of    hfe    a 
malignant  element  is  always  to  be  sus- 
pected.     The   curious   observation   has 
been  made  by  Gelle  that  these  structures 
sometimes    show    renewed    activity    at 
the  menopause. 

Series  of  57  cases  found  in  literature 
in  which  a  considerable  amount  of  tis- 
sue was  found  in  the  pharyngeal  vault 
of  adults.  In  most  cases  it  was  possi- 
ble to  make  the  diagnosis  by  posterior 
rhinoscopy,  but  sometimes  it  was  nec- 
essary to  use  the  finger.  The  growths 
varied  in  size  and  distribution,  but  were 
always  of  considerable  size,  and  usually 
sprang  from  the  angle  between  the  roof 
and  posterior  wall  of  the  pharyngeal 
vault.  They  were  usually  soft,  pulpy, 
and  friable,  particularly  so  in  the  older 
subjects.  Thirty  of  these  cases  were 
between  20  and  30  years  of  age,  15  be- 
tween 30  and  40,  and  12  over  40  years 
of  age.  Thirty-six  had  throat  symp- 
toms, 25  ear  symptoms,  10  tuberculosis, 
1  cervical  adenitis,  and  1  ethmoiditis. 
The  sexes  were  nearly  equally  divided. 
The  improvement  following  operation 
was  much  better  in  the  decade  between 
20  and  30  years  of  age  than  in  patients 
over  40.  D.  M.  Barstow  (N.  Y.  Med. 
Jour.,  May  6,  p.  899,  1905). 

PATHOLOGY.  —  Lymphoid  cells 
embedded  in  a  reticulum  of  connective 
tissue  containing  small  blood-vessels 
and  nerves,  the  retiform  adenoid  tissue 
of  His,  and  enclosed  in  a  mucous  mem- 
brane covered  by  columnar  ciliated 
epithelium,    constitute   adenoid  vegeta- 


tions. The  relative  proportion  of  these 
elements  varies  with  the  age  of  the 
patient,  the  duration  of  the  disease,  and 
the  frequency  and  intensity  of  acute 
inflammatory  attacks,  to  which  this  tis- 
sue is  very  liable.  In  young  subjects 
cells  predominate  and  the  tissue  is  soft, 
friable,  and  vascular ;  in  older  ones  con- 
nective tissue  is  in  excess  and  the  mass 
is  more  dense  and  hard. 

As  a  matter  of  clinical  convenience 
adenoids  are  sometimes  divided  into 
soft  and  hard,  Avhich  are,  of  course, 
merely  grades  of  the  same  pathological 
process.  In  very  young  children,  also, 
a  temporary  intumescence  takes  place 
in  consequence  of  gastrointestinal  dis- 
turbance or  other  cause,  when  many 
of  the  subjective  symptoms  of  ade- 
noids are  presented.  This  condition, 
naturally,  calls  for  different  treatment 
than  an  organized  hyperplasia.  Morbid 
changes .  are  not  confined  to  the  epi- 
pharynx,  but  involve  adjacent  lymphoid 
structures.  Cystic  transformation  and 
other  disorders  of  the  pharyngeal  bursa 
have  been  particularly  described  by 
Tornwaldt.  A  cyst  of  the  bursa  may 
reach  extreme  dimensions  and  occa- 
sionally small  cysts  are  met  with  in  the 
adenoid  tissue,  but  the  importance  of 
these  conditions  has  been  somewhat 
exaggerated.  The  idea  once  expressed 
by  Woakes  that  adenoid  vegetations 
are  papillomatous  in  structure  is  not 
sustained  by  modern  views. 

PROGNOSIS.— Under  present-day 
methods  of  attacking  the  disease  the 
prognosis  is  good,  both  as  to  arrest  of 
the  morbid  process  and  reHef  of  asso- 
ciated symptoms.  Only  in  case  the  con- 
dition has  been  extreme  in  degree  or 
duration  organic  changes  may  have  been 
estabhshed,  for  example  in  the  ears, 
which  are  irremediable.  Chronic  otor- 
rhea due  to  adenoids  cannot  be  cured 


398 


ADENOID    VEGETATIONS    (KNIGHT). 


while  the  latter  are  allowed  to  persist. 
Likewise  impaired  hearing  and  tinnitus 
due  to  occlusion  of  the  Eustachian  tube 
from  pressure  or  congestion  must  be 
reached  through  removal  of  an  adenoid 
m_ass.  Recurrence  of  adenoids  may  take 
place  in  certain  cases  of  pronounced 
lymphatism  (status  lymphaticus),  in 
which  predisposing  factors  cannot  be 
wholly  eliminated,  or  when  an  opera- 
tion for  removal  has  been  done  very 
early  in  life.  The  suspicion  remains, 
however,  that  some  alleged  relapses  are 
realty  examples  of  incomplete  removal. 
These  partial  operations  are  explained 
in.  a  measure  by  A.  A.  Bliss  on  the 
ground  that  the  lymphoid  tissue  pene- 
trates the  fissures  of  the  vomerosphe- 
noidal  articulation  (canales basis vomeri 
of  Harrison  Allen),  where  it  is  more  or 
less  inaccessible.  Extreme  vascularity 
of  the  region  and  the  fact  that  the 
adenoid  is  often  made  up  of  separate 
and  distinct  bundles  also  contribute  to 
the  possibility  of  apparent  recurrence, 
which  is  really  a  growth  of  tissue  that 
has  evaded  the  knife. 

It  is  safe  to  say  that  no  operation  in 
the  upper  air  tract  confers  more  grati- 
fying and  positive  benefits  than  an 
adenectomy  properly  done.  There  has 
been  much  controversy  as  to  the  thor- 
oughness with  which  morbid  tissue 
should  be  removed,  one  side  advocating 
extirpation  of  every  vestige  and  the 
other  averring  that  such  a  course  is 
ultraradical.  When  we  reflect  upon  the 
wide  distribution  of  lymphoid  tissue  in 
the  so-called  ring  of  Waldeyer,  or 
lymphoid  triangle,  the  conclusion  is 
forced  upon  us  that  absolute  eradica- 
tion is  impracticable,  even  if  desired. 
What  we  accomplish  in  a  given  case  is 
extraction  of  the  most  salient  and  dis- 
eased portions :  the  consequent  im- 
provement in  air  supply  and  in  other 


respects  enables  nature  to  do  the  rest. 
This  statement  is  not  to  be  taken  as  a 
defense  of  superficial  operating,  or  as 
a  suggestion  that  we  may  trust  nature 
to  supply  defects  involved  in  our  own 
negligence.  Postoperative  shrinkage  of 
any  considerable  remnants  is  not  to 
be  expected,  yet  there  are  limits  of 
safety  beyond  which  we  may  not  pass 
and  anatomical  conditions  which  are 
insuperable.  Certainly  erasion  of  the 
mucous  membrane  through  its  whole 
thickness,  so  as  to  replace  glandular 
secreting  tissue  by  scar  tissue,  is  to  be 
strongly  deprecated. 

Case  of  a  child  of  7  years,  who  had 
been  operated  upon  three  years  ear- 
lier for  adenoid  vegetations  without 
accident,  but  without  benefit.  A  sec- 
ond operation  was  performed  two 
years  later,  after  which,  on  returning 
home,  the  patient  passed  a  great  deal 
of  blood  by  vomit  and  by  stool.  A 
third  operation  for  enlarged  tonsils 
was  also  performed  without  special 
incident.  Nevertheless,  the  child  never 
breathed  freely  by  the  nose,  and  con- 
tinually kept  the  mouth  open.  The 
writer  found  an  incomplete  adhesion 
between  the  soft  palate  and  the  phar- 
ynx consecutive,  in  all  probability,  to 
the  second  intervention.  The  pharyn- 
geal orifice  behind  the  uvula  was  too 
small  to  permit  the  passage  of  an 
adenoid  curette.  On  being  enlarged 
the  opening  offered  ample  space  for 
respiration.  Courtade  (Annales  des 
mal.  de  I'oreille,  du  lar.,  du  nez,  et  du 
pharynx,  Aug.,  1910). 

Case  of  a  young  woman  suffering 
from  nasal  insufficiency,  due  to  the 
presence  of  large  adenoids,  removal 
of  which  was  followed  at  once  by 
commencing  atresia.  The  case  being 
referred  to  the  writer,  he  advised  op- 
eration, but  this  was  declined.  The 
closure  soon  became  complete,  and  in 
May,  1909,  she  consented  to  opera- 
tion. An  incision  was  made  through 
the  adhesion,  and  a  strip  of  gauze  was 
passed  through  •  the  nose  into  the 
mouth,   and   the   ends   attached   over 


ADENOID    VEGETATIOx\S    (KNIGHT). 


399 


the  lips.  This  was  left  for  three  days, 
when  sloughing  commenced,  and,  fear- 
ing extensive  destruction  of  tissue, 
the  gauze  was  removed.  Subsequent 
treatment  consisted  of  dilatation  twice 
a  day  with  the  probe  or  finger.  When 
reported,  six  months  later,  the  phar- 
ynx was  perfectly  free  and  the  pa- 
tient's voice  was  normal.  Wolf?  Fru- 
denthal  (Laryngoscope,  May,  1910). 

Adenoid  tissue  is  present  in  the 
vault  of  the  pharynx  in  1  out  of 
every  4  recruits.  The  fact  of  its 
presence  should  be  noted  on  the  rec- 
ord of  the  physical  examination  in 
order  that  due  weight  may  be  given 
to  it  as  a  factor  in  producing  defective 
hearing  when  cases  of  this  sort  come 
up  for  discharge  for  disability  or  pen- 
sion. All  large  adenoids  should  be 
excised  on  entry  into  the  service,  and 
smaller  masses  if  associated  with 
pathological  changes  in  the  middle 
ears.  Refusal  to  consent  to  operation 
should  disqualify  applicants  for  en- 
listment in  the  artillery  branch  of  the 
service  or  transfer  to  that  branch. 
Every  2  out  of  3  recruits  who 
have  adenoids  have  visible  changes 
in  the  middle  ears.  Fifty  per  cent,  of 
the  cases  who  do  not  have  adenoids, 
but  who  do  have  hypertrophied  ton- 
sils, have  changes  in  the  middle  ears. 
Changes  in  the  middle  ears  without 
the  presence  of  either  adenoid  or  ton- 
sillar hypertrophy  are  unusual,  and 
occur  in  only  1  case  out  of  12, 
and  in  the  case  in  which  it  occurs  it 
is  usually  associated  with  hypertro- 
phic rhinitis.  In  other  words,  in 
11  cases  out  of  12  which  show 
changes  in  the  middle  ears,  ade- 
noid or  tonsillar  hypertrophy  will  be 
found.  One  out  of  every  3  cases 
with  adenoids  will  also  have  hyper- 
trophied tonsils.  Two  out  of  every 
3  cases  with  hypertrophied  ton- 
sils will  also  have  adenoids.  Recruits 
with  marked  hypertrophy  of  the  ton- 
sils should  have  the  glands  excised, 
whether  they  have  had  repeated  at- 
tacks of  acute  tonsillitis  or  not.  Ade- 
noids do  not  undergo  spontaneous 
atrophy  in  young  adults.  Le  Wald 
(Military  Surgeon,  May,  1910). 


In  a  small  proportion  of  cases  breath- 
ing b}^  the  natm-al  channels  is  not  at 
once  resumed.  This  is  due  simply  to 
the  habit  of  mouth-breathing,  or  to  im- 
perfect development  of  the  air  tract 
from  prolonged  disuse.  In  the  former 
case  the  habit  is  soon  corrected  by  some 
device  for  binding  up  the  chin  and 
keeping  the  mouth  closed  during  sleep. 
In  the  latter  the  difficulty  is  greater  and 
it  may  be  a  long  time  before  the  normal 
respiratory  current  is  restored.  These 
cases,  fortunately  rare,  are  most  dis- 
appointing to  operator  and  parents  and 
yield,  if  at  all,  only  to  careful  attention 
to  hygiene  and  to  measures  tending  to 
promote  development.  The  co-opera- 
tion of  the  dentist  is  enlisted  for  cor- 
rection of  the  oral  deformity,  widening 
the  dental  arch  and  thus  depressing  the 
floor  of  the  nose  and  increasing  t':-: 
diameters  of  the  nasal  passages.  It 
is  best  -not  to  delay  this  beyond  the 
sixth  or  seventh  year  (E.  A.  Bogue), 
although  surprising  results  may  be 
achieved  much  later. 

Two  other  causes  of  continued  diffi- 
culty in  breathing  after  adenectomy 
have  been  described :  one  is  extraor- 
dinary prominence  of  the  bodies  of 
the  cervical  vertebrae  (J.  E.  Newcomb), 
and  the  other  is  a  paresis  of  the  sus- 
pensory apparatus  of  the  hyoid  bone 
and  the  tongue,  so  that,  Avhen  the  mus- 
cles are  relaxed  in  sleep,  the  tongue 
falls  back  and  occludes  the  glottis 
(Harrison  Allen). 

In  the  experience  of  Payson  Clark 
mouth-breathing  persisted  in  35  out  of 
75  cases  whose  subsequent  history 
could  be  learned.  Over  500  others 
were  not  traced  and  it  is  fair  to  assume 
that  the  above  percentage  might  be 
greatly  reduced. 

Faulty  habits  of  speech  are  to  be  re- 
formed by  careful  exercises  under  com- 


400 


ADENOID    VEGETATIONS    (KNIGHT). 


petent  supervision.  The  palatal  muscles 
having  been  long  curbed  in  their  action 
need  to  be  properly  educated. 

TREATMENT.  —  Until  Wilhelm 
Meyer,  in  1868,  gave  to  the  world  the 
results  of  his  careful  studies,  but  little 
had  been  done  in  diagnosis  or  treatment 
of  adenoids.  A  few  scattered  refer- 
ences are  found  in  literature  many 
years  before  his  day,  and  the  valuable 
researches  of  Luschka  and  others  in  the 
anatomy  of  this  region  are  well  known, 
but  no  serious  attempts  were  made  to 
remove  from  the  postnasal  region  cer- 
tain obstructions,  and  their  exact  nature 
was  not  fully  understood  until  Meyer 
began  his  investigations. 

In  the  hope  of  escaping  surgery 
various  local  astringent  applications  and 
methods  of  treatment  have  been  ad- 
vised, all  of  which  are  more  or  less 
futile,  except  in  the  vascular  or 
"cyanotic"  adenoid  of  some  writers. 
In  these  cases  instillations  of  adrena- 
lin chloride,  1  to  5000,  followed  by  fine 
sprays  or  vapors  of  mentholized  albo- 
lene  are  of  service.  Glycerite  of  tan- 
nin and  other  astringents  can  have 
little  or  no  permanent  effect  while  the 
underlying  cause  remains.  Anemia, 
gastrointestinal  derangements,  or 
other  disorders  must  be  corrected  by 
proper  hygiene,  diet,  and  general 
medication  as  indicated. 

Internal  medication  offers  but  little. 
With  anemic  or  chlorotic  children  one 
is  often  inclined  to  temporize  and  try 
to  build  up  the  system  by  means  of 
iron  and  other  tonics,  but  the  speedy 
improvement  in  general  condition 
following  surgical  intervention  is 
conclusive  proof  that  the  main  cause 
of  the  constitutional  depression  lies 
in  the  local  disorder,  upon  which 
medication  alone  has  little  or  no 
effect. 


Experience  with  opotherapy  is  still 
too  limited  to  justify  a  final  verdict. 
Some  authorities  assert  that  under  its 
use  reduction  in  volume  of  lymphoid 
hypertrophy  is  so  rapid  as  to  eliminate 
the  necessity  of  surgical  intervention. 
In  this  connection  attention  is  drawn 
to  the  danger  of  too  thorough  eradica- 
tion lest  neighboring  glands  be  stimu- 
lated to  excessive  functional  activity 
and  increased  growth. 

The  internal  and  local  use  of  iodine 
for  its  sorbefacient  effect  has  not  had 
pronounced  success.  The  Bier  suction 
hyperemia  treatment,  for  which  very 
temperate  claims  are  made  in  hyper- 
trophy of  the  faucial  tonsils,  does  not 
seem  to  have  been  applied  to  adenoids. 
The  tubes  figured  by  Meyer-Schmieden 
for  aspirating  the  nasal  chambers  and 
the  sinuses  would  make  but  little  im- 
pression in  the  postnasal  space,  al- 
though good  results  in  atrophy  of  the 
nasopharynx  are  mentioned. 

At  one  time  certain  "breathing  exer- 
cises" were  loudly  vaunted  as  a  cure 
for  adenoids.  The  shallow  character  of 
respiration  practised  by  most  people 
and  the  health-giving  value  of  deep 
breathing  are  generally  comprehended 
in  these  days,  especially  in  connection 
with  the  class  of  cases  under  considera- 
tion. Meyer  appreciated  the  fact  that 
a  dense  hyperplasia  cannot  be  dissipated 
by  breathing  exercises,  or  by  measures 
tending  to  promote  the  general  health, 
or  designed  to  exert  a  contractile  effect 
upon  the  morbid  growth.  His  early 
essays  at  removal  were  made  with  a 
small  "ring  knife"  passed  through  the 
anterior  naris  and  guided  by  a  finger 
inserted  behind  the  velum.  It  was  soon 
found  possible  to  operate  more  easily 
and  expeditiously  through  the  mouth, 
and  in  consequence  today  the  instru- 
ment shops  are  flooded  with   forceps. 


ADENOID    VEGETATIONS    (KNIGHT). 


401 


guillotines,    and    curettes    designed    to 
facilitate  this  procedure. 

In  adopting  a  plan  of  operation  the 
principles  of  thoroughness,  gentleness, 
and  celerity  are  to  be  observed.  By  the 
first  is  meant  not  a  clean  sweep  of  all 
t!ie  soft  parts  down  to  the  bone,  but  a 
removal  of  projecting  tabs  that  can  be 
detected  by  the  examining  finger.  The 
second  is  insured  by  selection  of  instru- 
ments that  include  in  their  bite  generous 
segments  of  tissue.  Thus  the  need  of 
frequent  reintroductions  is  obviated  and 
the  parts  are  spared  unnecessary  vio- 
lence and  contusion.  Finally,  while 
undue  haste  is  to  be  avoided,  it  is  well 
to  abbreviate  as  much  as  possible  the 
period  of  narcosis.  We  are  prone  to 
underestimate  the  importance  of  this 
detail.  As  a  matter  of  fact,  a  large 
proportion  of  accidents,  both  immediate 
and  secondary,  can  be  traced  to  excess- 
ive crowding  of  the  anesthetic  at  the 
hands  of  one  who  is  not  expert  in 
its  management.  General  anesthesia 
should  always  be  in  charge  of  one 
trained  for  the  duty,  who  knows  how  to 
get  satisfactory  relaxation  with  a  mini- 
mum of  anesthetic. 

Preparation  of  the  Patient. — While 
adenectomy  may  not  be  properly  con- 
sidered a  major  operation,  yet  it  is  by 
all  means  to  be  postponed  in  the  pres- 
ence of  any  acute  local  disturbance,  or 
of  concurrent  general  disorder,  or  when 
an  epidemic  of  any  contagious  disease 
is  prevailing.  The  advice  once  given  by 
Lennox  Browne  to  operate  during  an 
attack  of  diphtheria,  with  a  view  of 
averting  the  necessity  of  a  tracheotomy, 
is  refuted  by  the  modern  mode  of  treat- 
ment in  that  disease.  Locally  an  at- 
tempt to  secure  an  aseptic  operative 
field  by  the  use  of  antiseptics  is  hope- 
less. The  parts  should  be  cleansed  of 
seeretion  by  douching  with  warm  nor 


mal  salt  solution,  but  anything  be- 
yond that  is  superfluous.  Nasal  ste- 
nosis from  overgrowth  or  deformity 
should  be  corrected  at  the  same  time, 
or' by  a  preliminary  operation  if  very 
extensive.  Large  faucial  tonsils  which 
dnterfere  with  manipulations  should 
first  be  excised. 

Bleeders  should  be  avoided,  or  pre- 
pared by  a  few  doses  of  calcium  chlo- 
ride or  lactate.  The  strange  conflict  of 
opinion,  both  in  the  laboratory  and  in 
the  clinic,  as  to  the  effect  of  calcium 
upon  the  coagulability  of  the  blood 
tends  to  weaken  confidence,  but  pos- 
sibly should  rather  teach  us  to  use  it  in 
larger  doses  than  has  hitherto  been 
the  custom.  The  weight  of  evidence  is 
strongly  in  favor  of  calcium  lactate, 
some  authorities  asserting  that  the  chlo- 
ride is  practically  inert  (W.  K.  Simp- 
son). The  former  is  more  agreeable  to 
take,  and'  thus  far  no  unpleasant  con- 
sequences from  larger  doses  have  been 
experienced. 

Clinical  experience  shows  that  cal- 
cium lactate  has  a  controlling  influ- 
ence in  hastening  the  coagulation  of 
the  blood.  Its  efiicacy  is  more 
marked  in  hemophilic  cases  where 
the  coagulation  is  delayed  than  in 
cases  of  normal  coagulation  time. 
Before  operation,  especially  on  ton- 
sils and  adenoids,  careful  inquiry 
should  be  made  relative  to  any  hemo- 
philic heredity  or  tendency.  In  sus- 
picious cases  the  coagulation  period 
should  be  determined  before  opera- 
tion. It  is  questionable,  if  not  posi- 
tively contraindicated,  whether  such 
operations  should  be  undertaken  in 
hemophilic  cases  other  than  under  the 
most  extreme  urgency.  In  all  cases 
of  operation  for  the  removal  of  ton- 
sils and  adenoids,  calcium  lactate 
should  be  given  for  a  period  prior  to 
and  after  the  operation,  both  for  its 
possible  effect  in  diminishing  the  im- 
mediate hemorrhage  and  in  prevent- 
ing   secondary    surface    hemorrhage. 


1-26 


402 


ADENOID    VEGETATIONS    (KNIGHT). 


Of  the  calcium  salts,  the  lactate  is 
more  positive  in  its  results,  is  more 
agreeable  to  administer,  and  is  less 
irritating  to  the  stomach.  Simpson 
(Medical  Record,  Sept.  25,  1909). 

The  bowels  should  be  evacuated  by 
a  saline  laxative  and  no  solid  food 
and  no  milk  given  for  at  least  six 
hours  beforehand. 

Position  of  the  Patient. — The  erect 
position  is  advocated  by  some,  because 
it  is  that  to  which  we  are  accustomed 
in  routine  work,  the  loss  of  blood  is 
less,  and  debris  and  blood  tend  to  escape 
forward  rather  than  backward  toward 
the  glottis.  Moreover  it  is  thought  that 
the  ears  are  in  less  danger  as  a  result  of 
freedom  from  accumulations  at  the 
openings  of  the  Eustachian  tubes.  The 
position  on  the  side  is  favored  by  others 
on  account  of  the  tendency  of  blood 
and  secretions  to  gravitate  to  the  de- 
pendent side  and  drain  off  through  the 
nose  and  mouth. 

After  all  has  been  said,  the  recumbent 
position  seems  to  be  the  most  convenient 
for  all  concerned  and  is  free  from  risk, 
provided  the  anesthesia  be  not  profound 
and  the  reflexes  are  preserved.  In  such 
case  foreign  material  approaching  the 
larynx  is  promptly  ejected,  and  what 
finds  its  way  into  the  stomach  is  thrown 
up  before  complete  recovery  from  the 
anesthetic.  WitL  attention  to  this  point, 
the  so-called  Rose's  position,  the  head 
being  dependent,  is  not  essential.  In 
adults  and  under  local  anesthesia  the 
upright  position  is  preferable. 

When  the  operator  selects  the  recum- 
bent position,  the  body  should  be  hori- 
zontally on  the  back,  the  head  being 
neither  flexed  nor  extended.  With  the 
head  extended  the  cervical  curve  of  the 
spinal  column  is  increased.  Ln  this 
position  the  operator  is  liable  to  cut 
deeply  into  the  structures  of  the  poste- 
rior pharyngeal  wall,  which  will  be 
stripped   down  by  the   curette.     A  lat- 


eral position  favors  the  drainage  of 
blood  from  the  pharynx  and  in  no  way 
inconveniences  the  surgeon  in  remov- 
ing the  tonsils.  For  the  latter  purpose 
a  small  guillotine  is  better  than  a  large 
one,  and  is  not  so  liable  to  slip.  F.  C. 
Carle   (Lancet,  May  13,  p.  1265,  1905). 

Anesthesia. — In  children  under  one 
year  the  adenoid  growth  is  so  soft  and 
friable  that  it  can  be  readily  broken 
down  with  the  fingernail  and  no  anes- 
thetic is  necessary.  An  artificial  nail 
adjusted  to  the  fingertip  (Creswell- 
Baber,  Motais)  has  no  advantage  over 
a  curette,  and  rather  hampers  freedom 
of  manipulation.  Local  anesthesia  with 
cocaine,  stovaine,  or  alypin  is  re- 
served for  adults  and  for  children  old 
enough  to  be  manageable. 

Method  of  anesthetizing  the  pharyn- 
geal tonsil  by  infiltration,  the  needle 
being  passed  through  the  nostril.  First 
of  all,  a  camel's  hair  brush  is  soaked  in 
a  10  to  20  per  cent,  solution  of  cocaine, 
passed  through  one  nostril,  slightly  up- 
ward toward  the  upper  border  of  the 
posterior  nares,  and  left  there  for  a 
few  minutes.  The  process  is  repeated 
on  the  other  side.  The  deeper  parts 
are  caused  to  shrink,  so  that  the  upper 
border  of  the  posterior  nares  and  the 
adenoid  tissue  behind  becomes  visible 
by  anterior  rhinoscopy.  The  camel's 
hair  brush  is  then  gently  rubbed  over 
these  parts  until  they  are  superficially 
completely  anesthetic. 

To  anesthetize  the  pharyngeal  tonsil 
proper,  the  most  satisfactory  drug  is 
B-eucaine  in  a  warm  5  per  cent,  solu- 
tion with  0.8  per  cent,  of  NaCl.  Co- 
caine is  unsuitable,  as  more  concen- 
trated solutions  are  required  than  are 
necessary  for  ordinary  infiltration  an- 
esthesia. Novocaine  is  unreliable.  The 
eucaine  solution  can  be  sterilized  by 
boiling,  is  but  slightly  toxic,  and  is  not 
followed,  as  are  the  vasoconstrictors, 
'by  secondary  paresis  and  hemorrhages. 
Its  action  is  increased  by  the  addition 
of  5  drops  of  adrenalin  to  each 
syringeful.  The  capacity  of  the 
syringe    employed    by    the    writer    is 


ADENOID    VEGETATIONS    (KNIGHT). 


403 


slightly  more  than  2  c.c.  (about  34 
minims).  The  needle  is  passed  into 
one  nostril  backward  and  slightly  up- 
ward toward  the  upper  margin  of  the 
orifice  of  the  posterior  naris,  where  it 
impinges  on  the  mucous  membrane 
of  the  anterior  part  of  the  roof  of  the 
pharynx,  and  the  insertion  of  the 
pharyngeal  tonsil  a  short  distance 
external  to  the  septum.  This  should 
be  done  under  the  guidance  of  the 
eye. 

Considerable  pressure  is  required  to 
force  the  fluid  into  the  tissues,  and  an 
easy  flow  indicates  that  the  needle  has 
not  traveled  sufficiently  upward  to  the 
pharyngeal  roof.  The  process  is  re- 
peated through  the  opposite  nostril,  half 
a  syringeful  being  injected  on  either 
side.  After  waiting  a  short  time  the 
adenoids  can  be  removed,  in  the  great 
majority  of  cases  entirely,  painlessly. 
F.  Hutter  (Wien.  med.  Woch.,  Oct.  10, 
p.  2263,  1908). 

Although  certain  statistics,  hke  those 
given  by  C.  A.  Parker,  from  Golden 
Square  and  St.  Bartholomew's  Hos- 
pitals, are  partial  to  chloroform,  it  is 
the  general  belief  that  this  agent  is 
especially  dangerous  in  lymphatism  and 
should  never  be  used  (F.  W.  Hinkel). 
The  danger  is  said  to  be  less  when  it  is 
joined  with  oxygen.  Nitrous  oxide 
gas  is  universally  admitted  to  carry 
the  least  risk,  but  it  is  too  transient 
for  any  but  the  simplest  case.  Com- 
bined with  oxygen,  its  effect  is 
slightly  more  prolonged  and  in  other 
respects  it  is  satisfactory  (W.  E. 
Casselberry).  When  used  as  a  pre- 
liminary to  ether  in  what  is  known 
as  the  gas-ether  sequence,  with  a  Ben- 
nett inhaler,  the  process  of  narcosis 
is  rendered  as  agreeable,  rapid,  and 
safe  as  possible.  By  this  method  a 
much  smaller  quantity  of  ether  is 
needed  with  proportionate  reduction  in 
stimulation  of  mucous  secretion  and 
less  of  unpleasant  after-effect,  two  of 


the  chief  objections  to  ether.  Braden 
Kyle  quotes  Royer  to  the  effect  that 
secretion  is  lessened  by  adding  to  the 
ether  a  few  drops  of  oil  of  Hungarian 
pine.  The  disagreeable  odor  of  ether 
may  be  partially  prevented  by  first 
pouring  a  little  cologne  water  in  the 
mask,  and  thus  the  confidence  of  a 
timid  patient  may  be  secured.  By  many 
operators  the  "drop"  method  of  giving 
ether  is  preferred,  especially  in  young 
children,  and  thereby  the  strain  upon 
the  chest  walls  incident  to  the  use  of  a 
closed  inhaler  is  avoided.  By  some  the 
use  of  morphine,  atropine,  or  chlore- 
tone  to  reduce  mucus  secretion  is  ad- 
vised. A  clear  operative  field  may  be 
procured  with  the  ingenious  suction 
apparatus  advocated  by  Alexander  and 
Gwathmey  (N.  Y.  Med.  Jour.,  March 
11,  1911). 

Those  who  oppose  general  anesthesia 
refuse  to- admit  the  fact  that  the  shock 
without  it,  especially  in  a  nervous  child, 
overbalances  any  risk  incurred  when 
the  plan  just  outlined  is  pursued.  It  is 
almost  indispensable  when,  as  often 
happens,  the  palatal  tonsils  must  be  re- 
moved or  other  instrumentation  done 
at  the  same  time. 

Ethyl  bromide  and  ethyl  chloride, 
the  latter  said  to  be  the  less  objec- 
tionable, have  no  supreme  advantage 
and  are  not  proved  to  be  free  from 
risk.  According  to  Lermoyez,  the 
■difficulty  in  regulating  the  dose  of 
ethyl  chloride,  owing  to  its  great 
volatility,  is  overcome  by  giving  it 
with  a  suitable  mask,  whereby  the 
quantity  inhaled  is  precisely  known. 
The  Apperson  inhaler  is  highly  recom- 
mended, from  3  to  5  grams  of  the  anes- 
thetic being  required  for  a  short  opera- 
tion. The  drug  is  so  rapidly  eliminated 
that  after-effects  are  few  or  absent. 
Other  good  features  claimed  for  it  by 


404 


ADENOID    VEGETATIONS    (KNIGHT). 


those  experienced  are  ease  of  adminis- 
tration and  rapidity  of  action.  It  may 
be  given  prior  to  other  anesthetics,  or 
alone  continuously  for  an  indefinite 
time  without  regard  to  the  position  of 
the  patient,  upright  or  prone  (G.  F. 
Hawley). 

At  the  Royal  Infirmary  of  Edin- 
burgh, the  experience  of  T.  D.  Luke 
has  been  so  gratifying  that  he  rec- 
ommends ethyl  chloride  as  a  matter 
of  routine  for  short  operations.  On  the 
other  hand  Z.  Mennell,  at  St.  Thomas's, 
London,  notes  the  frequent  occurrence 
of  pulmonary  embolism  at  that  institu- 
tion since  the  introduction  of  ethyl 
chloride.  He  attributes  it  to  increased 
coagulability  of  the  blood  caused  by  the 
drug,  and  on  this  account  has  abandoned 
its  use.  Those  who  advocate  ethyl 
bromide  ascribe  disasters  with  it  to 
the  use  of  an  impure  product,  or  to 
the  mistake  of  having  substituted  for 
it  ethylene  bromide.  In  addition  we 
are  enjoined  to  give  it  en  masse,  ad- 
mitting no  air,  and  to  continue  the 
administration  no  longer  than  one 
minute  (A.  R.  Solenberger).  Most 
operators  will  find  sixty  seconds  too 
short  a  time  for  thorough  work. 

The  Schleich  inhalation  mixture 
(E.  Mayer)  and  the  A.  C.  E.  mixture 
are  urged  by  some,  but  have  no  spe- 
cial attraction. 

If  the  operation  is  to  be  done  in  the 
upright  position,  it  is  customary  to  give 
the  anesthetic  to  the  patient  lying  down 
and  to  slowly  elevate  the  body  when  all 
is  ready.  Special  operating  chairs  have 
been  devised  for  this  purpose  (T.  R. 
French). 

The  question  of  safety  being  of  the 
first  importance,  too  much  stress  cannot 
be  laid  upon  the  necessity  of  choosing  a 
reliable  anesthetic  and  a  trustworthy 
anesthetist. 


It  would  be  strange  if  in  this  psycho- 
therapeutic era  an  escape  from  the  an- 
noyance and  risks  of  general  anesthesia 
were  not  sought  in  the  line  of  sugges- 
tion. Accordingly  we  find  proposed 
"mental  suggestion  as  a  substitute 
for  anesthetics  in  the  removal  of  ton- 
sils and  adenoids  from  children"  (F. 
D.  Gulliver).  The  number  of  children 
amenable  and  of  operators  capable  of 
exercising  the  requisite  psychic  influ- 
ence must  be  extremely  small.  Yet  the 
method  is  said  to  be  in  successful  op- 
eration in  one  of  our  large  metropolitan 
clinics. 

Insufflation  anesthesia,  or  the  forc- 
ing of  ether  vapor  tO'  the  lungs 
through  a  tracheal  tube  (Jackson 
direct  laryngoscope),  is  pronounced 
by  C.  A.  Elsberg,  of  A'lount  Sinai 
Hospital,  who  introduced  the  method 
and  devised  an  excellent  apparatus 
for  the  purpose,  "ideal"  in  operations 
in  the  upper  air  tract,  as  regards  pre- 
vention of  aspiration  of  blood  and 
mucus  and  as  to  rapidity  and  safety 
of  narcosis.  This  view  is  confirmed 
by  C.  H.  Peck  from  experience  with 
a  number  of  cases  at  Roosevelt  Hos- 
pital. The  numerous  experiments  by 
S.  J.  Meltzer  at  the  Rockefeller  In- 
stitute justify  his  opinion  that  it  is  the 
"safest  and  most  effective  way"  of  ad- 
ministering ether.  He  finds  chloro- 
form far  less  safe,  but  it  may  be  given 
for  short  operations  with  confidence 
under  proper  supervision.  Recovery 
is  said  to  be  prompt  and  free  from  the 
usual  discomforts.  In  using  this 
method  the  anesthetist  avoids  inter- 
fering with  the  operator.  Another 
great  advantage  is  that  it  permits 
giving  a  supply  of  air  to  the  lungs 
without  the  action  of  the  respiratory 
muscles,  if,  perchance,  artificial  respi- 
ration becomes  necessary. 


ADENOID    VEGETATIONS    (KNIGHT). 


405 


Instruments  and  Methods. — Chem- 
ical caustics  and  the  electric  cautery 
have  been  generally  superseded  by  in- 
struments for  extracting  the  morbid 
tissue  instead  of  destroying  it  and 
allowing"  it  to  slough  away. 

Caustics  are  available,  if  ever,  only 
in  tractal)le  patients  and  under  guid- 
ance of  the  rhinoscopic  mirror,  the 
palate  being  held  forward  with  a  re- 
tractor (White)  or  by  means  of  elastic 
ligatures  (flexible  catheters)  passed 
through  the  nares  and  out  of  the  mouth, 
the  nasal  and  buccal  ends  being  tied 
or  clamped  together.  Under  cocaine 
the  process  is  not  extremely 
painful.  Silver  nitrate  and 
chromic  acid  have  been  used 
in  tliis  way.  Without*  the  ut- 
most care  and  the  use  of  a 
guarded  applicator  there  is  danger  of 
excessive  damage  and  violent  reaction. 
The  electric  cautery  point  or  loop  is 
more  precise  and  manageable,  but  at 
best  these  methods  are  tedious  and  un- 
satisfactory. They  are  reserved  for 
hematophiliacs  and  those  who  refuse  to 
be  cut.  In  other  cases  the  cold-wire 
snare,  the  guillotine,  forceps,  and  the 
curette  provide  a  wide  choice  of  cutting 
instruments.    A  straight  snare  (Jarvis) 


White's  palate  retractor. 

may  be  passed  through  the  naris,  or  a 
curved  one  behind  the  velum  (Bos- 
worth).  It  is  successful  only  when  the 
lymphoid  tissue  is  so  bunched  in  the 
vault  that  the  wire  can  readily  encircle 
its  base.  It  is  apt  to  slip  and  include 
only  superficial  portions. 

The     guillotine     or     adenotome     of 


Schuetz,  modified  by  Cradle,  works 
admirably  in  the  vault,  but  not  on 
the  lateral  walls.  We  have  finallv 
a  great  variety  of  forceps  and  curettes 
adapted  to  any  age  or  situation.     It  is 


Schuetz-Gradle  adenotome. 


well  to  have  several  sizes,  large  for  the 
main  operation  and  small  for  the  fossae 
of  Rosenmiiller  and  the  choanas.  The 
majority  of  forceps  cut  laterally;  those 
of  Schuetz  cut  anteroposteriorly.  The 
edges  not  crossing  like  scissors,  the 
operation  is  practically  a  combination 
of  avulsion  and  cutting.  The  small 
forceps  of  Hooper  cross  slightly,  and 
the  large  fenestrated  blades  of  Cradle's 
forceps  have  a  defined  scissors  action. 

The  writer  advocates  operating  with- 
out systemic  anesthesia  whenever  feasi- 
ble, since  he  notes  that  the  statistics 
show  a  disproportionately  large  number 
of  deaths  when  chloroform  is  used. 
With  proper  skill  the  operation  can  be 
done  as  effectively  in  the  wide-awake 
child  as  in  the  anesthetized  subject. 
Nor  in  his  own  practice  has  he  noted 
any  unpleasant  sequels  of  operation. 
He  uses  for  ordinary  adenoid  opera- 
tions no  instrument  but  the  guillotine- 
shaped  adenotome  of  Schuetz  of  his 
own  modification.  This  brings  out  the 
whole  tonsil  intact.  When  the  adenoids 
are  extensive  the  instrument  is  pressed 
firmly  toward  one  Rosenmueller  fossa, 


406 


ADENOID    VEGETATIONS    (KNIGHT). 


and  after  its  action  is  reinserted  toward 
the  other  side.  The  work  is  done 
quicker,  with  less  hemorrhage,  and  as 
efficiently  as  with  any  other  instrument. 
He  abolishes  actual  pain  almost  com- 
pletely by  injections  of  20  per  cent. 
cocaine  solution,  supplemented  bj^ 
adrenalin  applied  to  the  pharynx  up 
to  its  roof.  Gradle  (Chicago  Med. 
Record,  Nov.,  p.  634,  1907). 


tonsillotome  (Alackenzie^  ^lathieu),  or 
punch  (Alyles,  Roberts),  and  the  pa- 
tient is  quickly  turned  on  the  side  to 
allow  blood  and  secretion  to  drain. 
Bleeding  having  subsided,  the  patient  is 
replaced  on  the  back.  A  little  more 
anesthetic  may  now  be  required.  The 
nasopharynx  is  explored  with  the  finger 
to  determine  the  extent  and  distribution 
of  the  growths. 


Den  hard's  mouth  gag. 


The  early  instruments  for  scraping 
ere  the  sharp  spoons  of  Justi  and  of 
Trautmann.  Curettes  are  now  made 
larger  and  of  different  sizes  and  shapes, 
and  some  are  provided  with  forks  to 
catch    the    resected    fragments.      Such 


The  soft  palate  being  dragged  for- 
ward with  the  left  forefinger,  a  forceps 
with  large  blades  is  passed  into  the 
vault,  opened  to  full  width,  and  while 
the  left  index  finger  presses  the  blades 
firmly  upward  the  instrument  is  tightly 


Brandegee's  adenoid  forceps. 


complicating  attachments  are  a  disad- 
vantage rather  than  otherwise.  The 
simpler  the  instrument,  the  easier  it  is 
to  handle  and  keep  aseptic. 

While  the  anesthetic  is  being  given, 
the  patient  lies  flat  on  the  back.  After 
the  muscles  are  somewhat  relaxed,  a 
Denhard  mouth-gag  is  inserted  on  the 
left  side.  The  operator  stands  on  the 
patient's  right.  If  the  palatal  ton- 
sils are  enlarged,  they  are  first  re- 
moved with  snare   (Farlow,  Moseley), 


closed.  The  forceps  of  Brandegee, 
or  the  author's,  is  preferred.  Then 
by  a  slight  twisting  movement  the 
pendulous  masses  which  have  been 
seized  are  torn  from  their  attach- 
ments. Again  the  patient  is  turned 
on  the  side.  After  a  few  moments 
the  pharynx  is  explored  for  rem- 
nants which  need  to  be  removed  with 
small  forceps  (Gleitsmann,  Loewen- 
berg)  or  curette  under  guidance  of  the 
finger.     By  many  operators  a  curette 


ADENOID   VEGETATIONS    (KNiGHT). 


407 


of  the  Gottstein  or  Beckmaun  pal- 
tern  is  used  for  the  whole  operation. 
A  curette  of  proper  shape  and  size,  and 
correctly  used,  certainly  sweeps  off  the 
tissue  most  effectually.  The  blade,  al- 
ways quite  sharp,  is  slipped  behind  the 
velum  and  crowded  from  below  upward 
close  to  the  posterior  margin  of  the 
vomer,  and  then  by  a  quick  movement 
pushed  backward  and  slightly  down- 
.ward  through  the  base  of  the  growth. 


The  blades  are  directed  by  the  finger 
passed  behind  the  velum,  and  in  any 
case  it  is  a  useful  instrument  for  clear- 
ing out  the  postnasal  arches,  where 
fragments  are  sometimes  missed  and 
afterward  give  trouble. 

Even  when  the  postnasal  adenoids 
have  been  completely  extirpated,  the 
part  is  apt  to  remain  vulnerable  for 
some  time,  often  highly  sensitive  to 
atmospheric  changes,  so  that  the  at- 


'Knight's  adenoid  forceps. 


A  clean  complete  removal  is  thus  en- 
sured at  least  as  to  the  vault  itself, 
when  the  conformation  of  the  region  is 
normal.  Unless  the  blade  is  passed 
close  to  the  posterior  surface  of  the 
velum  and  is  made  to  hug  the  vomer  in 
its  upward  movement,  pendent  masses 
are  apt  to  be  crowded  into  the  choange. 
By  giving  the  shaft  of  the  curette  a 
curved  or  bayonet  shape  it  is  possible 


tacks  may  not  altogether  cease  until 
steps  have  been  taken  to  brace  up  the 
relaxed  mucous  membrane  and  re- 
duce its  susceptibility  to  chills.  It  is, 
therefore,  advisable  to  remove  the 
patients,  soon  after  the  operation,  to 
the  seaside,  choosing  a  situation 
which  is  moderately  bracing,  but  not 
bleak.  He  should  be  taught  to  breathe 
as  much  as  possible  through  the  nose, 
and  should  pass  the  greater  part  of 
his  time  in  the  open  air.     There  are 


Gottstein' s  adenoid  curette. 


to  avoid  the  obstacle  offered  by  the  in- 
cisor teeth  or  by  the  palate  and  thus 
reach  farther  forward  in  the  vault 
(J.  Fein).  Other  curettes  are  made 
heart-shaped,  so  as  to  actually  enter  the 
nares  on  either  side  of  the  septum 
(C.  E.  Hunger). 

The  nasal  route  for  reaching  adenoids 
has  been  revived  by  Freer,  who  recom- 
mends for  the  purpose  a  modification 
of  Ingal's  straight  nasal  cutting  forceps 


two  applications  which  are  very  ser- 
viceable in  these  cases.  Tvi^ice  a  day 
a  solution  of  resorcin  in  normal  sa- 
line (5  or  10  grains  to  the  ounce, 
with  the  addition  of  half  a  dram  of 
tincture  of  hamamelis)  should  be  in- 
stilled into  the  nostrils  as  the  child 
lies  on  his  back  with  his  head  sup- 
ported by  a  pillow.  Five  or  six  drops 
may  be  used  to  each  nostril  with  a 
"dropper,"  allowing  the  fluid  to  trickle 
down  into  the  pharynx.  After  using 
these  drops  for  a  week  we  can  begin 


408 


ADENOID   VEGETATIONS    (KNIGHT). 


to  paint  the  pharynx.  The  best  ap- 
plication for  this  purpose  is  a  solution 
of  IS  grains  of  potassium  iodide  and 
12  of  iodine  in  an  ounce  of  water,  well 
sweetened  with  glycerin.  This  should 
be  applied  twice  a  day  to  the  pharynx 
with  a  brush,  taking  care  to  sweep 
the  brush  round  with  a  turn  of  the 
wrist  before  withdrawing  it,  so  as  to 
reach  as  high  up  as  possible  behind 
the  soft  palate.  This  application  not 
only  checks  morbid  oversecretion  by 
curing  the  nasopharyngeal  catarrh, 
but  also  puts  an  end  to  laryngeal  irri- 
tation and  favorably  influences  the 
glandular  enlargement.  In  fact,  this 
is  the  very  best  method  of  treatment 
for  acutely  swollen  cervical  glands, 
and  as  long  as  the  latter  remain  of 
elastic  softness,  varying  in  size  from 
time  to  time  according  to  the  amount 
of  laryngeal  worry,  we  may  expect 
them  to  be  dissipated  by  this  means. 
Smith  (Practitioner,  Jan.,  1910). 

Accidents  and  Complications. — The 

most  serious  accident  is  hemorrhage, 
whicli  may  be  first  shown  by  pallor  and 
rapid,  flickering  pulse.  Small  children 
should  be  closely  watched  and  not 
allowed  to  sleep  continuously  for  sev- 
eral hours  after  operation.  The  con- 
trast between  the  quiet  and  the  pre- 
viously noisy  breathing  often  creates 
enough  anxiety  to  enforce  this  caution. 
Bleeding  usually  ceases  spontaneously 
in  a  very  few  minutes.  The  total  loss 
of  blbod  is  difficult  to  estimate ;  accord- 
ing to  C.  G.  Coakley,  from  2  to  8  ounces 
is  the  ordinary  quantity.  If  in  excess 
or  too  long  continued,  measures  to  check 
it  must  be  adopted. 

An  interesting  and  a  rather  promis- 
ing hemostatic  agent,  suggested  by  Ba- 
telli  in  1910  (thrombokinase),  has  re- 
cently been  prepared  by  L.  W.  Strong 
in  the  laboratory  of  the  Manhattan  Eye, 
Ear  and  Throat  Hospital.  His  method 
differs  slightly  from  the  original,  and 
he  believes  he  has  obtained  a  "ferment 
body"  fairly  stable  and  effective  in  all 


situations  where  a  local  application  is 
possible.  It  occurs  in  the  form  of  crys- 
tals or  scales,  of  which  a  very  small 
quantity  will  promptly  induce  coagula- 
tion. It  does  not  afifect  the  caliber  of 
the  blood-vessels  and  is  not  adapted  to 
internal  use.  Several  members  of  the 
staflf  of  the  hospital  have  resorted  to  it 
in  various  conditions  with  satisfaction. 
As  yet  it  does  not  appear  to  have  been 
subjected  to  such  a  crucial  test  as  would 
be  ofifered  by  a  case  of  hematophilia. 
Its  field  of  usefulness  is,  therefore,  still 
undetermined.  It  is  important  that  the 
surface  to  which  it  is  to  be  applied 
should  be  made  as  dry  as  practicable  by 
pressure  with  a  cotton  tampon.  In  this 
particular  a  difficulty  might  be  met 
with  in  the  case  of  very  free  hemor- 
rhage. 

In  March,  1902,  the  writer  removed 
the  tonsils  and  adenoid  vegetation,  at 
the  same  sitting,  from  a  child  of  11 
years.  The  adenotomy  was  done  with 
the  curette  of  Kirstein,  and  the  hem- 
orrhage was  not  more  than  usual.  An 
hour  afterward  it  was  reported  that  the 
child  was  losing  considerable  blood.  A 
postnasal  tampon  was  inserted ;  during 
the  night  a  new  hemorrhage  developed, 
followed  by  death.  The  boy  was  suf- 
fering from  leukemia  of  a  lymphatic 
form. 

Six  months  later  a  boy  applied  to 
B;urger  to  have  the  three  tonsils  re- 
moved. The  pharyngeal  tonsil  was 
pale,  and  of  a  cyanotic  appearance,  with 
several  hemorrhagic  points.  Cautioned 
by  the  above  accident,  he  first  had  an 
examination  of  the  blood  made.  Leu- 
kemia was  found  pronounced  (35  leu- 
cocytes to  400  chromocytes),  and  the 
child  was  placed  in  the  medical  clinic. 
Some  weeks  after,  the  child  died, .  and 
the  autopsy  confirmed  the  first  diag- 
nosis. 

The  danger  of  fatal  hemorrhage  is 
very  rare ;  with  the  exception  of  two 
or  three  cases  of  hemophilia,  there  are 
only  3  cases  of  fatal  adenotomy  re- 
ported.   Burger  made  2200  in  the  space 


ADENOID    VEGETATIONS    (KNIGHT). 


409 


of  nine  years  without  the  least  aecident. 
M.  Burger  (Revue  Heb.  de  Laryn., 
d'Otol.  et  de  Rhin.,  Jan.  30,  1904). 

Operations  upon  the  pharyngeal  ton- 
sils   are    generally    considered    without 
danger,  yet  wound  infection  and  hem- 
orrhage,   although    comparatively    rare, 
do  occur  frequently  enough  to  warrant 
careful    attention.      Hemorrhages    may 
be   divided   into  two   types:    those   ap- 
pearing at  the   time  of  operation,   and 
those    occurring   some   time   afterward. 
In  the  first  instance  the  causes  lie  in 
a    constitutional    or    a    local    condition, 
the  most  important  of  which  is  hemo- 
philia.    This   is   shown  by   family   and 
personal  history.     If  there  exists  abso- 
lute  proof   of    a   hemophilia,   naturally 
the  operation  would  be  denied.     But  in 
such  cases  as  appear  relatively  doubt- 
ful the  operation  should  be  given  the 
benefit  of  the  doubt.     An  unrecognized 
leukemia  can  be  the  cause  of  excessive 
hemorrhage.     Characteristic  is  the  livid 
bleached  color  of  the  tonsils.     Opera- 
tion in  such  cases  can  produce  the  same 
untoward     results     as     in     hemophilia. 
Among  other  diseases  which  impose  the 
danger  of  severe  postoperative  hemor- 
rhage are  nephritis,  heart  lesions,  etc., 
which,    however^    appear    so    rarely    in 
cases  needing  adenoidectomy  that  they 
can  be  neglected. 

Many  authors  have  associated  severe 
postoperative  hemorrhage  with  the  co- 
incidence of  the  operation  and  men- 
struation. About  1  per  cent,  of  cases 
have  postoperative  hemorrhage.  Injury 
to  neighboring  parts,  and  especially  the 
leaving  of  partly  removed  tissue  shreds, 
are  the  important  factors.  The  former 
more  often  leads  to  hemorrhage  im- 
mediately following  the  operation,  and 
only  to  after-bleeding  when  the  blood- 
clot  covering  the  lesion  is  accidentally 
removed.  Mucous  membrane  shreds 
hanging  from  the  wound  are  found  in 
over  50  per  cent,  of  after-hemorrhages. 
Hemorrhages  occurring  after  several 
days  generally  follow  sudden  muscular 
exertion,  such  as  sneezing,  blowing  the 
nose,  etc.,  and  are  due  to  dislocation 
of  the  exudate  covering  the  wounded 
surface.  Healing  had  progressed  so  far 
after  a  week's  time  that  bleeding  is  no 


longer  to  be  feared.  Haymann  (Archiv 
f.  Laryngologie,  Bd.  xxi,  S.  15,  1908- 
1909). 

Reference  has  already  been  made  to 
the  internal  use  of  calcium  chloride 
or  lactate  in  hemophilia,  as  well  as  to 
local    applications    of   the   new    "fer- 
ment,"   thrombokinase.     Locally,    in- 
stillations of  adrenalin  chloride,  1  to 
1000,  are  sometimes  effective.    Direct 
pressure  by  means  of  a  gauze  tampon 
crowded    up    into    the    vault    in    the 
grasp  of  a  postnasal  forceps  is  usually 
successful.  The  gauze  may  be  soaked 
in  a  saturated  solution  of  tannogallic 
acid    (1   part  gallic,  3  parts  tannic), 
one  of  the  cleanest  and  most  active 
hemostatics.    Signs  of  collapse  are  to 
be    combated    by    saline    injections, 
stimulants,  constricting  the  extremi- 
ties,   and    similar    expedients.     Even 
after  extreme  exsanguination  the  re- 
pair of  waste  is  generally  rapid,  but 
may  need  to  be  encouraged  by  the  use 
of  ferruginous  tonics  or  other  medica- 
tion. 

Such  being  the  case,  the  proposal 
of  Iglauer  to  transform  adenectomy 
into  an  "almost  bloodless"  operation  by 
packing  the  postnasal  space  with  a 
tampon  of  rubber  sponge  the  moment 
the  adenoid  mass  has  been  removed  is 
of  doubtful  utility.  The  plan  suggested 
is  like  that  followed  in  plugging  the 
posterior  nares  for  epistaxis.  The  tam- 
pon is  ready  before  the  operation  is 
begun,  and  the  tape  attached  to  it 
is  used  as  a  palate  retractor  during 
instrumentation. 

The  handle  of  the  forceps  cutting 
laterally  should  not  be  too  much  de- 
pressed lest  the  margin  of  the  vomer  be 
nipped  between  the  blades.  Care  should 
be  taken  to  keep  the  blade  of  a  cutting 
instrument  in  the  middle  line  of  the 
vault:     if  tilted  to  one  side,,  there  is 


410 


ADENOID    VEGETATIONS    (KNIGHT). 


danger  of  harm  to  the  Eustachian 
cushion. 

A  rare  and  interesting  compHcation, 
torticolHs,  has  been  described  by  several 
writers  and  is  probably  "due  to  sepsis  or 
to  excessive  energy  in  the  use  of  instru- 
ments. It  disappears  spontaneously  in 
a  few  days  and  is  worthy  of  note  only 
because  of  the  unnecessary  alarm  to 
which  it  may  give  rise. 

Laceration  of  the  velum  would  seem 
to  be  inexcusable,  but  has  been  known 
to  occur  with  rough  handling  of  an  ex- 
cessively large  instrument,  or  from  at- 
tempting to  make  use  of  a  cutting  edge 
in  a  struggling  child,  or  before  one 
is  quite  sure  that  the  instrument  has 
passed  beyond  the  plane  of  the  velum 
and  is  well  within  the  cavity  of  the 
nasopharynx.  Finally,  the  mucous 
membrane  may  be  stripped  up  over  an 
excessive  area,  if  too  dull  an  instrument 
be  used,  or  if  it  be  forced  too  deeply 
into  the  tissues.  With  the  exception  of 
the  first-mentioned,  hemorrhage,  these 
accidents  are  obviously  all  results  of 
faulty  manipulation. 

Attention  has  been  called  by  Wyatt 
Wingrave  and  others  to  a  peculiar 
transitory  rash  resembling  that  of  scar- 
latina at  times  following  removal  of 
adenoids  or  tonsils.  It  merits  notice 
only  for  the  danger  that  it  might  be 
confounded  with  a  more  serious  infec- 
tious exanthema.  No  precise  theory  of 
the  phenomenon  is  propounded,  whether 
septic  or  nervous,  although  marked 
leucocytosis  is  demonstrable  for  a  week 
or  ten  days  after.  Several  cases  of 
alleged  sepsis  have  been  recorded,  but 
in  many  the  histories  are  by  no  means 
conclusive.  A  case  of  fatal  meningitis, 
believed  to  be  septic,  has  been  reported 
by  Shurly;  two  similar  cases  have  been 
noted  by  Putnam,  who  expresses  the 
opinion  that  such  sequelse  are  not  un- 


common. An  interesting  case  of  cav- 
ernous sinus  thrombosis  in  which  the 
surface  of  the  basilar  process  of  the 
occipital  bone  had  been  shaved  off 
together  with  an  adenoid  mass  with  a 
Beckmann  curette  is  a  graphic  warning 
against  the  use  of  extraordinary  force 
(A.  E.  Wales).  Cases  of  pharyngeal 
abscess,  inflammation  of  the  cervical 
glands,  endocarditis,  and  acute  rheuma- 
tism have  been  met  with  by  various 
observers  after  adenectomy. 

Several  instances  of  lighting  up  of 
latent  tuberculosis  by  adenectomy  have 
been  reported  (Lermoyez,  Chappell). 
It  is  perhaps  more  correct  to  say  that 
tubercle  bacilli  lying  in  the  operative 
field  have  ready  admission  to  the  cir- 
culation through  the  divided  lymph- 
channels,  whence  general  infection  fol- 
lows. In  the  majority  of  cases  the 
adenoid  tuberculosis  is  undoubtedly 
secondary  to  a  focus  in  the  lung  or  else- 
where which  is  excited  to  activity  by 
the  surgical  shock  of  operation.  In  a 
primary  case  the  results  of  removal  are 
favorable  (E.  H.  White),  but  there 
must  always  be  difficulty  in  deciding 
this  question  of  priority. 

The  hyperplastic  pharyngeal  tonsil 
often  contains  micro-organisms,  and 
these  are  mainly  pyococcal  forms.  The 
bacteria  for  the  most  part  lie  near  the 
surface,  and  the  infection  usually  oc- 
curs from  the  surface,  with  or  without 
demonstrable  lesion  of  the  epithelium. 
Primary  tuberculosis  of  adenoids  is 
probably  more  common  than  most  pre- 
vious studies  show.  Sixteen  per  cent, 
of  the  series  contained  tubercle  bacilli, 
10  per  cent,  with  characteristic  lesions 
of  tuberculosis.  The  tubercle  bacilli 
were  present  in  small  numbers.  The 
lesions  in  primary  tuberculosis  of  the 
adenoid  are  generally  close  to  the  epi- 
thelial surface  and  focal  in  character. 
Occasionally  they  may  be  found  in  the 
deeper  parts  of  the  pharyngeal  lym- 
phoid "tissue.      The    pharyngeal    tonsil 


ADENOID    VEGETATIONS    (KNIGHT). 


411 


may  be  a  portal  of  entry  for  the  tuber- 
cle bacillus  and  other  micro-organisms 
in  localized  or  general  infections.  A.  J. 
Lartigau  and  M.  Nicoll,  Jr.  (Amer. 
Jour.  Med.  Sci.,  June,  p.  1031,  1902). 

Examination  of  35  specimens  of  ade- 
noids from  children ;  in  1  case,  a  boy 
aged  3  years,  suffering  from  caseat- 
ing  tuberculous  glands  behind  the  left 
sternomastoid  the  pharyngeal  tonsil 
showed  numerous  tubercles.  In  cases 
of  tuberculosis  of  the  cervical  glands 
where  no  other  source  of  infection  can 
be  found  the  pharyngeal  tonsil  must  be 
regarded  with  suspicion.  Ivens  (Lan- 
cet, Sept.  16,  p.  817,  1905). 

Primary  tuberculosis  occurs  in  a  cer- 
tain proportion  of  all  cases  of  adenoids. 
From  the  figures  of  other  observers  and 
the  author's  this  seems  to  be  about  5 
per  cent.  This  is  regarded  as  a  con- 
servative estimate.  In  determining  the 
presence  of  adenoid  tuberculosis  the 
histological  method  is  the  most  satis- 
factory. Tuberculosis  does  not  appear 
to  be  an  important  factor  in  the  pro- 
duction of  adenoid  hypertrophy.  Ade- 
noids and  tonsils  are  the  important 
channels  of  infection  in  tuberculosis  of 
the  cervical  glands. 

In  the  development  of  pulmonary  tu- 
berculosis adenoids  may  sometimes  be 
direct  channels  of  infection,  but  their 
importance  is  probably  more  often  in- 
direct by  predisposing  to  catarrhal  in- 
flammations of  the  upper  respiratory 
tract.  E.  Hamilton  White  (Amer. 
Jour.  Med.  Sci.,  Aug.,  p.  228,  1907). 

The  writer  found  evidences  of  tu- 
berculosis in  the  growths  in  only  1 
of  27  cases  of  adenoid  vegetation,  and 
in  this  case  it  was  evidently  second- 
ary.    Wikner   (Hygieia,  April,   1910). 

An  interesting  case  is  mentioned  by 
J.  L.  Morse,  in  which  "adenoids  were 
removed  from  an  infant  of  five  months 
during  the  early  stage  of  tuberculous 
meningitis,  tubercle  bacilli  being  found 
in  the  adenoid  tissue."  The  possibility 
of  infection  by  this  route  is  looked  upon 
as  a  strong  reason  for  operating  in  the 
early   months   of   life,    even    with    the 


certainty  that  a  repetition  will  be  called 
for  at  a  later  period. 

Spasm  of  the  glottis  requiring  tra- 
cheotomy, as  ini  cases  of  his  own,  is 
believed  by  Holger  Alygind  to  be  not 
infrequent  in  adenectomy  without  an- 
esthesia in  rachitic  children,  and  one 
should  be  prepared  for  such  an  emer- 
gency. 

The  writer  has  twice  witnessed  seri- 
ous disturbance  of  respiration  (laryn- 
gospasm  with  stridulous  inspiration  and 
marked  cyanosis  of  the  lips)  as  a  result 
of  adenotomy  without  use  of  chloro- 
form. Both  cases  were  children  under 
2  years  having  symptoms  of  rachi- 
tis. In  the  third  case,  in  a  boy  of  2 
years,  wath  rachitic  deformities,  there 
was  sudden  collapse  accompanied  wnth 
suspension  of  respiration  and  cyanosis 
consequent  to  adenotomy,  which  re- 
quired tracheotomy.  The  child's 
mother  later  declared  that  the  child 
was  subject  to  fits  of  suspension  of 
respiration  wath  cj^anosis.  On  two 
occasions  he  had  such  attacks  in  the 
presence  of  the  family  doctor,  and 
artificial  respiration  had  to  be  em- 
ployed. Holger  Mygind  (Hospital- 
stidende,  Nov.   18,  p.   1173,  1903). 

Case  in  which  a  very  large  adenoid 
removed  from  a  child  aged  6  years  gave 
rise  to  asphyxia  on  spasmodic  closure 
of  the  jaw  just  as  the  child  was  appar- 
ently under  complete  ether  anesthesia. 
The  writer  had  to  resort  to  artificial 
respiration,  hypodermic  injections, 
forcible  opening  of  the  jaw,  and 
traction  of  the  tongue  in  order  to  re- 
suscitate his  patient.  G.  L.  Richards 
(Laryngoscope,  Feb.,  p.  289,  1905). 

After-treatment.  —  The  control  of 
hemorrhage,  and  that  in  very  excep- 
tional cases,  is  practically  the  only 
indication  for  interference  during  con- 
valescence. If  catarrhal  secretion  is 
overabundant,  it  is  sometimes  desirable 
to  keep  the  parts  clean  with  a  douche 
or  coarse  spray  of  warm  normal  salt 
solution.  Drainage  from  this  region  is 
so  good  that  sepsis  is  almost  unknown, 


412 


ADIPOSIS    DOLOROSA    (DERCUM). 


and  it  is  well  to  abstain  from  the  use  of 
antiseptics,  either  in  solution  or  powder. 
In  order  to  prevent  the  formation  of 
adhesions,  the  passage  of  the  finger 
into  the  vault  for  a  few  days  after 
operation  has  been  recommended.  Al- 
though no  statistics  on  this  point  are 
available,  it  is  believed  that  adventitious 
bands  met  with  in  adult  life  are  due 
not  to  operative  interference,  but  to  at- 
trition and  erosion  of  lymphoid  masses 
in  childhood  which  have  been  neglected 
and  have  finally  undergone  spontaneous 
shrinkage. 

No  procedure  in  the  upper  air  tract 
has  added  so  much  to  the  vigor  of 
the  race  as  removal  of  adenoid  vege- 
tations, and  the  fact  must  be  admit- 
ted that  they  are  often  a  source  of 
disease,  even  when  their  volume  is 
not  sufficient  to  cause  obstructive 
symptoms.  Not  all  lymphoid  nodules 
demand  extraction :  only  those  which 
are  clearly  causing  disturbance,  or 
inviting  infection. 

Removal  of  adenoid  vegetation  has 
brought  about,  in  the  writer's  hands, 
recovery  of  2  cases  of  exophthal- 
mic goiter,  1  of  glaucoma  due  to 
lesion  of  the  fifth  pair  and  not  re- 
lieved by  iridectomy,  and  of  1  case 
of  Addison's  disease.  The  persistence 
of  the  craniopharyngeal  canal,  the 
vascular  communication  between  the 
pituitary  cavity  and  the  pharyngeal 
miucous  membrane,  the  presence  of 
an  accessory  pituitary  gland  encoun- 
tered sometimes  in  the  pharynx, 
might  cause  an  alteration  in  the  se- 
cretory function  of  the  pituitary 
gland,  and,  indirectly,  by  intermedia- 
tion of  the  grand  sympathetic  nerve 
and  of  the  spinal  marrow,  of  the  other 
glands  of  internal  secretion.  Popp 
(Annales  des  mal.  de  I'oreille,  du 
larynx,  du  nez,  et  du  pharynx,  Oct., 
1909). 

Charles  H.  Knight, 

New  York. 


ADIPOSIS.     See  Obesity. 

ADIPOSIS  DOLOROSA;  DER- 
CUM'S  DISEASE. 

[The  term  "Dercum's  disease"  is  that  by 
which  adiposis  dolorosa  is  generally  known 
in  Europe.  Hence  its  introduction  here  by 
the  Editors.] 

DEFINITION.— Adiposis  dolorosa 
derives  its  name  from  its  two  principal 
features,  namely,  fat  and  pain. 

[Objection  may  naturally  be  made  to  the 
form  of  the  word  "adiposis,"  as  it  is  of 
mixed  origin,  being  made  up  of  a  Latin  root 
joined  to  a  Greek  termination.  It  has,  how- 
ever, the  sanction  of  generations  of  use 
among  English-speaking  writers,  and,  be- 
sides, is  paralleled  by  other  mongrel  words 
in  common  use,  such  as  terminology,  which 
no  one  any  longer  questions.  The  correct 
Latin  form  of  the  word  would,  of  course, 
be  "adipositas,"  the  word  used  by  German 
writers.  However,  adipositas  is  equally  a 
coined  word,  a  word  artificially  made,  for  it 
is  not  used  by  any  Latin  writer.  The  real 
Latin  word  is  "obesitas,"  which,  as  purists, 
we  ought  to  use.     F.  X.  Dercum.] 

In  1888,  the  writer  described  the 
symptoms  which  constitute  this  affec- 
tion in  reporting  a  case  under  the  title 
of  a  subcutaneous  connective-tissue 
dystrophy.  Later,  in  1892,  he  grouped 
this  case,  a  second  described  by  F.  P. 
Henry,  and  a  third  discovered  in  the 
wards  of  the  Philadelphia  General  Hos- 
pital under  the  name  "adiposis  dolo- 
rosa," by  which  the  affection  has  since 
become  generally  known.  Within  the 
next  few  years  cases  were  published  by 
Collins,  Peterson,  Ewald,  Eshner,  Spil- 
ler,  Fere,  and  others.  In  1901,  Louis 
Vitaut  (These  de  Lyon,  1901,  "Maladie 
de  Dercum")  published  a  special  treat- 
ise on  the  subject.  His  description  of 
the  affection  was  so  full  and  accurate 
that  at  the  present  date  it  needs  but  lit- 
tle modification  and  but  few  additions ; 
the  latter  mainly  bear  upon  the  pathol- 
ogy of  the  affection.  Up  to  the  present 


ADIPOSIS    DOLOROSA    (DERCUM). 


413 


time  between  50  and  60  cases  have  been 
recorded.  [Among  the  more  important 
recent  papers  upon  the  subject  are 
those  of  Frankenheimer  (Jour.  Amer. 
Med.  Ass'n,  1908,  i,  p.  1012),  of  Price 
(Amer.  Jour.  Med.  Sci.,  May,  1909), 
and  the  thesis  of  Poirier,  Montpeher, 
1910.] 

SYMPTOMS    AND    COURSE.— 
The  development  of  the  disease  is  usu- 
ally slow  and  insidious.    A  woman  who, 
up   to   the   period   of   onset,   has   been 
well  and  occupied  with  her  usual  occu- 
pation notices  a  slight  pain  or  tender- 
ness in  this  or  that  portion  of  the  body. 
This    early   symptom   of    pain   is   very 
variable  in  character  and  in  intensity. 
Most  often  it  is  a  sensation  of  smarting 
or  stinging  more  or  less  annoying  be- 
cause of  its  persistence.    Sometimes  the 
pain,  even  in  the  beginning,  is  severe, 
though  this  is  unusual.    At  other  times 
the  onset  of  symptoms  is  preceded  by  a 
sensation  of  cold  in  regions  in  which 
pain  subsequently  makes  its  appearance. 
As  a  rule,  the  pains  at  first  are  not  very 
pronounced  and  the  patient  is  for  some 
time  able  to  follow  her  ordinary  occu- 
pation.   Furthermore,  the  pains  are  not 
persistent,   but   recur   at   intervals,   the 
patient  being  comfortable  for  hours  and 
sometimes  for  days  at  a  time.     Little 
by   little   the  pains   become   more   pro- 
nounced, they  increase  in  intensity  and 
are  then  also  accompanied  by  distinct 
local   changes.      The   patient   naturally 
examines  the  part  which  is  painful  and 
may  note  these  changes  herself.    Some- 
times there  is  a  little  flushing  of  the 
skin    and    sooner    or    later    a    swelling 
is  noted.     At  first  it  is  hardly  appre- 
ciable, but  gradually  becomes  more  pro- 
nounced.     The    swelling    may    give    a 
sensation  to  the  finger  of  a  rather  firm 
localized  edema.    As  a  rule,  it  is  in  the 
beginning  a  small  nodule, — smaller  than 


a  walnut,  rarely  larger.  Sometimes  a 
number  of  such  swellings  are  noted  at 
the  same  time.  The  affection  continues 
to  evolve,  usually  slowly;  the  pains  be- 
come more  intense  and  more  frequent, 
and  gradually  the  tumefactions  change 
their  character  and  finally  become  veri- 
table tumors  or  great  tumor  masses. 
In  rare  cases  the  fatty  deposit  appears 
to  make  its  appearance  without  either 
previous  or  concomitant  pain,  the  pain 
making  its  appearance  only  after  the 
enlargements  or  swellings  have  existed 
for  some  time.  This,  as  already  stated, 
is  unusual,  the  most  common  history  by 
far  being  that  just  outlined. 

The  pain  is  quite  commonly  paroxys- 
mal, though  in  long-established  cases  it 
may  be  continuous.  In  the  intervals  the 
tumefactions  are  usually  tender  or  pain- 
ful to  pressure. 

When  the  disease  is  well  established, 
we  may  distinguish,  as  pointed  out  by 
Vitaut,  4  cardinal  symptoms,  namely, 
tumor  formations,  pain,  asthenia,  and 
psychic  symptoms. 

The  sweUings  may  present  themselves 
under  three  different  aspects.  Some- 
times they  are  small,  of  variable  dimen- 
sions, distinct  from  one  another,  and 
readily  isolated.  Under  these  circum- 
stances they  present  what  Vitaut  has 
termed  the  nodular  form  of  the  disease. 
Sometimes  they  form  extensive  masses, 
invading  an  entire  limb  or  the  segment 
of  a  limb.  To  this  condition  Vitaut  has 
given  the  name  of  "localized  diffuse 
form."  Finally,  a  tumor,  properly 
speaking,  may  not  be  present,  but  the 
entire  body  may  be  augmented  in  vol- 
ume in  consequence  of  a  hyperplasia  of 
the  fatty  subconnective  tissue.  This  con- 
dition Vitaut  has  called  "the  general- 
ized diffuse  form." 

The   Nodular   Form. — The  nodular 
form  manifests  itself  at  first  by  pains. 


414 


ADIPOSIS    DOLOROSA    (DERCUM). 


variable  in  character,  stinging,  itching, 
smarting,  shooting,  soon  followed  by  a 
slight  redness  of  the  skin  and  a  slight 
induration  scarcely  appreciable  to  the 
finger.  If  we  examine  the  painful  area, 
we  feel  a  tumefaction,  usually  of  small 


changes,  so  that  it  no  longer  has  the 
appearance  of  a  simple  tumefaction,  biit 
that  of  an  actual  tumor.  Each  increase 
of  swelling  is  preceded  or  attended  by 
characteristic  pains.  The  latter  are 
sometimes  so  sudden  in  their  onset  and 


Author's  first  case     [Dercum.) 


size,  at  first  yielding  and  later  a  little 
more  resistant.  The  sensation  is  that 
of  a  firm  edema,  which  is  not  well  differ- 
entiated from  the  surrounding  tissue. 
The  tumefaction  appears  to  develop 
slowly  in  keeping  with  successive  at- 
tacks or  crises  of  pain.  Gradually  it 
becomes  somewhat  better  defined,  its 
volume    increases,    and    its    consistence 


so  severe  as  to  cause  the  patient  to 
cry  out.  During  the  height  of  the 
paroxysm,  the  tumor  may  resemble 
very  closely,  in  the  sensation  which  it 
gives  to  the  fingers,  a  "caking  breast." 
The  painful  crisis  having  passed,  it  is 
found  that  the  dimensions  of  the  swell- 
ing have  distinctly  increased.  It  has 
become    permanently    larger,    as    well 


ADIPOSIS    DOLOROSA    (DERCUM). 


415 


as  more  resistant  and  better  defined. 
After  repeated  paroxysms,  the  swelling 
resembles  a  distinct  tumor  more  and 
more  closely.  In  certain  portions,  the 
mass  may  appear  finely  lobulated,  while 
in  other  parts  it  gives  to  the  fingers  the 


capsulated.  Sometimes  after  a  crisis 
we  discover  around  the  tumor  a  well- 
defined  edematous  zone,  which  in  sub- 
sequent crises  undergoes  a  transforma- 
tion such  as  the  original  mass  itself  had 
undergone.     In  this  way  the  mass  may 


Case  of  adiposis  dolorosa  in  a  male.    (Dercum.) 


sensation  of  a  bag  of  worms  beneath 
the  skin.  Each  painful  crisis  leaves  be- 
hind it  very  appreciable  changes.  In 
an  area  where  nothing  existed  pre- 
viously, we  find  after  a  crisis  a  diffuse 
edematous  tumefaction ;  if  the  tume- 
faction has  existed  previous  to  the 
crisis,  we  find  it  transformed  into  a 
lobulated  tumor  more  or  less  well  en- 


eventually  attain  great  size.  The  vari- 
ous stages  of  the  evolution  of  these 
masses  can  be  followed  very  closely  by 
palpation.  One  and  the  same  patient, 
besides,  usually  presents  in  various 
regions  tumors  in  various  stages  of 
development. 

Painful  crises  supervene  usually  with- 
out appreciable  cause ;  at  times  they  are 


416 


ADIPOSIS    DOLOROSA    (DERCUM). 


provoked  by  trauma  and  at  others  they 
ensue  upon  unusual  exertion.  The  pa- 
tient is  frequently  very  positive  in 
stating  that  slight  contusions  of  the 
surface  or  that  excessive  fatigue  pro- 
vokes the  painful  crises. 

The  tumors  are,  of  course,  variable 
in  size.  Some  of  the  very  smallest 
may  be  no  larger  than  a  pea,  though 
so  small  a  mass  is  the  exception.  More 
frequently  the  mass  is  of  the  size  of 
a  walnut  or  a  small  orange.  Much 
larger  sizes  are  met  with.  The  larger 
masses  are  of  course  evident  to  ordi- 
nary visual  inspection ;  the  smaller  ones 
require  to  be  sought  for  by  palpation. 
If  we  examine  the  patient  attentively 
in  a  good  light,  we  are  struck  by  the 
changes  in  the  skin  in  certain  areas. 
In  places,  indeed,  it  presents  a  bluish 
tint  due  to  a  slight  superficial  veining, 
and  if  we  examine  such  a  region  by  the 
feel  we  frequently  discover  a  small 
subjacent  tumor.  Small  as  the  tumor 
may  be,  it  may  betray  its  existence  by 
this  bluish  tint  in  the  skin  which  covers 
it.  It  happens  sometimes  that  these 
small  tumors  become  confluent  and 
finally  form  a  single  large  mass.  Such 
a  mass  gives  rise  to  a  sensation  like  that 
of  a  varicocele  or  of  a  bag  of  worms. 

The  masses  do  not  appear  to  have  a 
special  localization;  they  are  sometimes 
symmetrical  in  the  beginning,  but  soon 
group  themselves  without  any  apparent 
order.  They  develop  by  preference 
over  the  limbs  or  in  the  segments  of  a 
limb.  In  some  patients  it  is  limited  to 
the  arms  and  thighs,  or  forearms  and 
legs  in  others.  Sometimes  we  find  them 
on  the  thorax,  abdomen,  and  lumbo- 
sacral region.  'The  face,  hands,  and 
feet  are  never  involved. 

The  relations  of  these  neoplasms  to 
the  surrounding  tissue-  vary  according 
to  the  degree  of  their  development.    In 


the  state  of  edematous  swelling,  they 
pass  without  exact  limitation  into  the 
surrounding  tissue.  The  skin  is  but 
slightly  movable  over  them.  Later, 
when  they  form  distinct  tumors,  more 
or  less  encapsulated,  they  are  mobile  in 
all  directions  and  the  skin  which  covers 
them  may  be  folded  above  them.  How- 
ever, they  are  slightly  adherent  to  the 
latter,  so  that  if  one  tries  to  displace  the 
superjacent  skin  the  movement  is  trans- 
mitted to  the  underlying  tumor.  Fi- 
nally it  may  be  noted  that  these  masses 
are  painful  not  only  during  the  crises, 
but  are  very  tender  to  pressure,  and  this 
tenderness,  as  already  pointed  out,  may 
persist  in  the  intervals  between  the 
paroxysms. 

The  Localized  Diffuse  Form. — The 
localized  diffuse  form  may  present  it- 
self primarily  or  it  may  develop  out  of 
the  nodular  form.  When  it  develops 
from  the  nodular  form^  it  is  because 
the  nodules  multiply  so  rapidly  that  they 
unite  and  become  confluent.  In  this 
way  a  more  or  less  voluminous  mass 
may  develop,  which  involves  a  portion 
of  a  limb  or  it  may  be  a  segment  of  a 
limb  or  even  an  entire  limb.  However, 
this  is  not  the  usual  method  of  origin 
of  the  localized  diffuse  form.  In  the 
nodular  form  the  separate  masses  are 
generally  so  small  and  the  evolution  so 
slow  that  the  patient  has  usually  been 
under  observation  for  some  time  before 
the  masses  become  confluent.  More 
frequently  the  localized  diffuse  form 
originates  spontaneously  and  rapidly  in 
an  entire  limb  or  a  segment  of  a  limb. 
In  such  a  case  the  pains  are  felt  over  a 
correspondingly  extensive  region.  At 
first  the  entire  region  presents  an 
edematous  swelling  easily  observable  by 
the  eye.  Subsequently  the  evolution  of 
the  mass  is  substantially  the  same  as  in 
the  nodular  form.     Painful  crises  are 


ADIPOSIS    DOLOROSA    (DERCUM). 


417 


here  again  present  antl  the  swelhng  in- 
creases in  size  with  each  successive 
attack.  Finally,  a  mass  is  formed  which 
is  resistant  and  painful  to  pressure.  It 
may  be  c|uite  smooth  or  it  may  be  finely 
lobulated,  or  separate,  apparently  en- 
capsulated tumors  may  be  found  im- 
bedded in  the  general  lipomatous  mass. 

Naturally,  in  the  localized  dififuse 
form  it  is  difficult  to  make  out  the 
limitations  as  clearly  as  in  the  nodular 
form.  The  masses  involve  more  espe- 
cially the  limbs,  excluding  save  in  the 
rarest  instances  the  hands,  the  feet,  and 
the  face;  not  rarely  they  are  found  on 
the  thighs  and  on  the  back.  The  tume- 
faction may  be  excessively  painful  and 
may  present  during  a  crisis  the  sensa- 
tion given  by  a  breast  distended  by 
milk  or,  to  repeat  a  term  already  used, 
a  "caked  breast." 

The  Generalized  Diffuse  Form. — 
The  generalized  diffuse  form  is  much 
less  characteristic  than  the  nodular  or 
the  localized  diffuse  form.  The  origin 
and  course  of  the  affection  is,  however, 
the  same.  The  edema  may  appear 
rapidly,  even  suddenly,  over  the  greater 
part  of  the  surface  of  the  body  and 
limbs,  exclusive  again  of  the  face, 
hands,  and  feet.  It  increases  progress- 
ively and  produces  a  general  lipoma- 
tosis. More  frequently  it  begins  in  a 
certain  part,  such  as  the  abdomen,  some- 
times upon  one  side,  and  then  diffuses 
itself  gradually  over  neighboring  por- 
tions of  the  trunk  and  limbs.  Other 
masses  may  make  their  appearance  at 
the  same  time  or  subsequently,  and,  be- 
coming confluent  with  the  original  mass 
and  each  other,  a  diffuse  lipomatosis 
results.  The  regions  affected  are  ordi- 
narily the  arms,  the  chest,  the  abdomen, 
the  hips,  and  the  thighs.  Contrary  to 
the  case  in  the  nodular  and  localized 
diffuse  forms,  the  hands  and  feet  are 


not  always  in  this  form  absolutely  free. 
At  an  advanced  stage  of  the  disease,  it 
is  not  unusual  to  see  small  masses  of 
lipomatous  tissue  over  the  thenar  and 
hypothenar  eminences  and  even  on  the 
soles  of  the  feet.  In  one  case  the 
writer  observed  even  a  slight  invasion 
of  the  face.  Only  the  back  of  the 
hands  and  the  backs  of  the  feet  escape 
invariably  the  lipomatous  invasion.  In 
consistence  the  swelling  is  resistant,  but 
much  less  so  than  in  the  nodular  form. 
The  mass  is  spontaneously  painful  and 
tender  to  pressure.  Sometimes  the 
suffering  owing  to  the  universal  tender- 
ness is  very  great.  Occasionally  it  is 
such  as  to  prevent  movement  on  the 
part  of  the  patient  and  to  immobilize 
him  in  his  bed. 

Of  the  three  forms  the  most  common 
is  the  nodular.  It  presents  a  special 
physiognomy,  which  makes  its  recogni- 
tion easy.  The  localized  diffuse  form 
resembles  certain  forms  of  ordinary 
lipomatosis,  but  it  is,  notwithstanding, 
differentiated  by  the  pain  and  other 
characteristics  still  to  be  considered. 
The  pains  are  never  absent.  They  are 
present  either  spontaneously  or  are 
readily  elicited  by  pressure.  Usually 
they  manifest  themselves  in  both  of 
these  ways.  Most  often  they  pre- 
cede the  appearance  of  the  edematous 
swelling.  Sometimes  they  come  on  at 
the  same  time  as  the  swelling;  more 
rarely  they  are  not  noted  until  after 
the  swelling  has  made  its  appearance. 
Slightly  marked  and  intermittent,  they 
become  more  violent  when  the  disease 
is  established.  The  pains  are  described 
by  the  patients  as  stinging,  burning, 
pinching,  darting,  or  even  lancinating. 
Most  commonly  they  are  darting  and 
radiate  or  diffuse  in  and  about  the 
nodules.  They  do  not  follow  the  large 
nerve    trunks    or    indeed    any    nerves. 


1—27 


418 


ADIPOSIS    DOLOROSA    (DERCUM). 


The  patient  describes  them  as  though 
they  were  situated  in  the  thickness  of 
the  masses.  The  muscles,  the  bones, 
and  joints  are  not  painful.  The  pains 
are  exaggerated  or  brought  on  by  pres- 
sure or  handhng.  If  the  fatty  accumu- 
lation is  considerable,  movement  and 
effort  may  increase  the  pain  to  such 
an  extent  that  the  patient  may  be 
obliged  to  remain  perfectly  quiet  during 
the  paroxysm  or  indeed  continuously. 
There  is  one  characteristic  which  one 
finds  in  all  cases,  namely,  the  parox- 
ysmal exacerbations  already  described. 
Suddenly  and  without  cause  or  follow- 
ing an  effort  or  trauma  the  patient 
again  feels  active  pain.  At  the  same 
time  the  new  formations  increase  in 
volume ;  if  it  concerns  a  nodule  the 
latter  is  surrounded  by  an  edematous 
zone  more  or  less  extended;  if  it  is  a 
case  of  diffuse  swelling  the  skin  in  this 
region  becomes  more  tense  and  the  cir- 
cumference of  the  mass  increases.  As 
the  pain  subsides,  the  swelling  recedes, 
but  never  to  its  former  dimensions. 
After  each  crisis,  the  volume  of  the 
new  formation  is  increased. 

All  or  almost  all  of  the  patients  pre- 
sent the  symptoms  of  a  general  asthe- 
nia. The  patient  is  very  readily  ex- 
hausted. Even  in  cases  in  which  the 
muscular  development  is  good,  this  fact 
is  early  noted.  In  cases  which  are  ad- 
vanced the  asthenia  is  very  pronounced. 
Sometimes  this  is  so  marked  that  the 
patient  is  unable  to  leave  the  bed. 
Sometimes  she  is  unable  to  change  even 
her  position  in  bed  largely  because  of 
her  weakness,  but  also  because  of  the 
pain  and  the  enormous  increase  in  the 
size  and  the  weight  of  the  limbs  and 
body  generally. 

The  psychic  symptoms  are  not  con- 
stant. However,  they  are  very  fre- 
quently present.     A   cerebral   asthenia 


or  ready  cerebral  exhaustion  is  rarely 
absent.  Many  patients  present  in  addi- 
tion great  irritability;  this  is  at  times 
so  great  as  to  be  attended  by  a  change 
in  character  and  disposition.  The  least 
opposition  may  enrage  the  patient  and 
not  infrequently  she  will  quarrel  with 
her  neighbors  in  the  wards  to  such  an 
extent  that  isolation  becomes  impera- 
tive. Sometimes  she  thinks  that  the 
other  patients  and  the  nurses  are  against 
her.  The  sleep  is  usually  broken  and 
disturbed  by  distressing  dreams  and 
nightmares.  One  of  Eshner's  pa- 
tients was  disturbed  mentally  to  such 
extent  as  to  necessitate  her  commit- 
ment to  an  asylum.  Hale  White's 
case  had  two  attacks  of  mental  dis- 
turbance. Giudiceandrea  has  noted 
delusions  of  persecution  and  a  true 
dementia. 

In  several  cases  lessened  sensibility 
to  touch,  pain,  and  temperature  have 
been  noted.  In  the  writer's  first  case 
there  were  found  areas  of  anesthesia, 
while  in  other  areas  the  sensibility  was 
diminished.  The  same  patient  com- 
plained of  velvety  sensations  in  the 
finger  tips  and  in  the  soles  of  the 
feet.  The  case  reported  by  Henry  pre- 
sented marked  disturbances  of  sensa- 
tion. Touch,  pain,  and  temperature 
were  sometimes  not  perceived ;  at  other 
times  confused.  In  Giudiceandrea's 
case  the  sensibility  to  pain,  on  the  other 
hand,  was  much  increased,  especially  in 
the  regions  corresponding  to  the  adi- 
posed  masses.  The  thermal  sensibility, 
again,  was  particularly  exquisite  in  the 
regions  in  which  there  was  no  trace  of 
the  neoplasms.  Hyperalgesia  was 
noted  by  Achard  and  Laubry.  Patients 
have  also  complained  of  sudden  sensa- 
tions of  cold  or  heat,  of  formication,  or 
of  cramps  in  various  parts  of  the  body. 
Headache  is  not  rare. 


At)iPOSiS    DOLOROSA    (DERCUM). 


419 


Disturbances  of  the  special  senses 
are  quite  frequent.  In  some  observa- 
tions there  was  noted  a  narrowing"  of 
the  visual  fields ;  in  others  various 
subjective  sensations,  such  as  phos- 
phenes,  muscte  voHtantes;  in  one  case 
amaurosis  was  noted,  which  began  to 
disappear  from  the  day  that  thyroid 
treatment  was  instituted,  and  in  a  case 
of  the  writer  there  was  present  a 
circinate  retinitis, — a  mass  of  partly 
fibrinous  and  hemorrhagic  exudate  in 
the  center  of  the  retina,  surrounded  by 
crescents  of  fatty  degeneration  in 
Mueller's  fibers. 

Diminution  of  auditory  perception 
has  been  noted  several  times.  In 
some  cases  tinnitus  more  or  less 
marked  has  been  recorded.  Smell 
and  taste  were  impaired  in  one  of  the 
writer's  cases. 

Vasomotor  disturbances  have  been 
very  frequently  noted.  The  skin  over 
a  nodule  may  present  no  changes 
whatever;  on  the  other  hand,  it  may 
be  noted  to  be  somewhat  injected 
during  a  crisis  of  pain,  or  much  veined 
and  slightly  bluish.  Occasionally  the 
face  is  much  flushed, — the  malar  re- 
gions, the  frontal  regions — or  it  may 
be  the  neck,  although  no  actual  indura- 
tion or  swelling  accompanies  the  change 
in  color. 

In  some  cases  cyanosis  of  the  ex- 
tremities and  transitory  edema  have 
been  noted.  Frequently  also  the 
patient  notices  that  his  flesh  bruises 
very  readily,  and  it  is  not  uncommon 
to  note  small  ecchymoses  on  various 
portions  of  the  limbs  and  trunk,  and 
at  times  these  evidently  make  their 
appearance  spontaneously  and  inde- 
pendently of  trauma.  Perhaps,  in 
keeping  with  this  fact  is  the  history, 
not  infrequently  obtained,  of  excessive 
menstruation     or     even     of     metror- 


rhagia. At  times  also  epistaxis  and, 
in  one  of  the  writer's  cases,  even 
hematemesis  are  noted. 

Trophic  changes  in  the  form  of 
ulcerations,  blebs,  and  bullae  have  been 
observed. 

It  is  important  also  to  add  that 
there  is  quite  commonly  a  marked 
dryness  of  the  skin.  Patients  them- 
selves comment  upon  this  and  ex- 
amination confirms  it. 


Adiposis  dolorosa  with  involvement  of 
the  joints.    (Dercum.) 

Among  unusual  complications  noted 
in  adiposis  dolorosa  are  changes  in 
the  joints.  Attention  was  first  directed 
to  this  by  Renon  and  Heitz,  who  in 
1901  presented  a  case  of  "adiposis  dolo- 
rosa with  multiple  arthropathies,"  be- 
fore the  Neurological  Society  of  Paris. 
In  addition  to  the  usual  symptoms  of 
the  affection  there  were  present  marked 
pain,  creaking,  and  limitation  of  move- 
ment in  numerous  joints.  A  skiagraph 
of  the  left  knee  failed  to  reveal  any 
alteration  of  the  articular  surface.  The 
knee-cap,  however,  was  a  little  thick- 
ened, and  its  structure  offered  a  some- 
what mottled  appearance.  The  syno- 
vial membranes  gave  rise  to  a  slightly 
opaque  shadow,  which  was  especially 
evident    at    the    cul-de-sac    under    the 


420 


Adiposis  dolorosa  (dercum). 


quadriceps  tendon.  This  shadow,  In- 
froit,  who  made  the  skiagraph,  re- 
garded as  due  to  fatty  thickening  of 
the  synovial  membrane. 

In  1902  the  writer  placed  on  record 
(Philadelphia  Medical  Journal,  Decem- 
ber 20th)  a  second  case  of  adi- 
posis dolorosa  with  involvement  of 
the  joints.  Skiagraphs  revealed  no 
changes  whatever  in  the  bones,  but 
some  thickening  of  the  tissues  about 
the  joints,  especially  about  the  knee- 
joints.  The  conclusion  was  justified 
that  there  was  present  a  marked 
thickening  of  the  synovial  membranes 
land  possibly  of  other  structures  in 
the  neighborhood  of  the  joints.  There 
w^as  a  marked  tendency  to  the  forma- 
tion of  fringes  and  rice  bodies.  The 
joints  appeared,  as  the  patient  ex- 
pressed it,  to  be  "loose,"  and  motion 
was  attended  by  considerable  pain. 
That  the  changes  observed  were  due, 
in  part  at  least,  to  fatty  infiltration, 
and  that  this  fat  was  painful,  just  as 
was  the  fat  in  the  tumor  masses  on 
the  surface  of  the  body,  afforded  the 
most  reasonable  explanation  of  the 
condition.  It  was  possible  also  that 
an  actual  synovitis  was  present. 
Rheumatism  could  not  offer  an  ade- 
quate explanation  of  the  conditions 
found,  while  rheumatoid  arthritis  was 
excluded  by  the  absence  of  changes 
in  the  bones  and  cartilages.  More 
recently  Price  has  made  studies  in 
the  joints  of  two  other  cases  con- 
firming these  findings. 

A  most  interesting  case  of  adiposis 
dolorosa  in  which  bony  changes  were 
noted  in  the  dorsal  vertebrje  and  in 
the  ribs  has  been  placed  on  record 
by  Price  and  Hudson  (Journal  Nervous 
and  Mental  Diseases,  April  19,  1909). 
Kyphoses  with  corresponding  de- 
formity and  reduction  in  size  of  the 


vertebrae  were  noted  in  the  dorsal 
region  and  confirmed  by  the  skia- 
graph. Similar  changes  were  noted 
in  the  ribs.  The  authors  call  atten- 
tion to  the  possible  significance  of 
these  findings  when  the  frequency  of 
pituitary  changes  in  adiposis  dolorosa 
is  borne  in  mind. 

The  course  of  adiposis  dolorosa  is 
essentially  chronic.  Its  progress  is 
slow,  the  patient  being  worse  or 
better  by  turns  in  accordance  with 
occurrence  of  paroxysms  of  pain.  In 
well-established  cases  the  suffering  is 
continuous,  subject  always  to  more  or 
less  marked  exacerbations. 

In  the  majority  of  cases  the  patients 
become  extremely  obese,  the  weight 
often  running  from  200  to  300  pounds ; 
in  others  again,  in  the  nodular  form,  the 
weight  may  undergo  only  a  moderate 
if  any  increase. 

The  symptoms  may  be  briefly  sum- 
marized as  follows :  fatty  deposit, 
pain,  general  asthenia,  and  psychic 
symptoms.  The  deposits  are  present 
either  in  the  nodular,  a  localized  dif- 
fused or  a  generalized  diffused  form. 
The  distinction  between  these  forms 
is  of  course  not  absolute,  as  combina- 
tions of  the  various  forms — or  transi- 
tional states — may  be  found  in  one 
and  the  same  patient.  The  deposits 
are  found  most  commonly  over  the 
trunk,  shoulders,  arms,  and  thighs ; 
the  forearms  and  legs  being  less  fre- 
quently affected  and  the  hands  and 
face  almost  never.  Pain  and  tender- 
ness upon  manipulation  of  the  swell- 
ings are  present;  spontaneous  pain, 
pain  occurring  in  paroxysms,  is 
also  present  unless  it  happens  that 
the  patient  is  observed  during  an 
interval  between  paroxysms.  Involve- 
ment of  the  nerve  trunks  is  rare,  though 
it  has  been  a  few  times  observed,  not- 


ADIPOSIS    DOLOROSA    (DERCUM). 


421 


ably  in  a  case  of  Bergerson's.  Anes- 
thesias are  rare,  hypesthesias  not  un- 
common, paresthesias  are  frequent ;  the 
latter  consist,  as  already  pointed  out,  of 
sensations  of  numbness,  cold,  burning, 
tingling,  crawling. 

The  general  asthenia  and  the 
mental  phenomena  have  been  already 
sufficiently  considered. 

The  tendon  reflexes  may  be  normal 
or  increased,  but  are  usually  dimin- 
ished and  sometimes  abolished.  In 
one  case,  that  of  Delecq,  the  skin 
reflexes  were  lost.  Coincident  gross 
nervous  disease  has  been  noted 
several  times.  Hemiplegia  and  apha- 
sia were  noted  in  one  case  ;  in  another, 
a  case  of  the  writer,  a  sclerosis  of  the 
columns  of  Goll  was  revealed  at  the 
autopsy,  and  in  still  another  there 
was  involvement  of  the  lateral  tracts. 

ETIOLOGY.  —  It  is  occasionally 
noted  that  the  patient  presents  a  neuro- 
pathic heredity;  not  infrequently  grave 
nervous  disorders  are  noted  among  the 
ancestors  or  collateral  relatives.  Now 
and  then  it  is  noted  that  other  members 
of  the  family  are  unusually  stout,  e.g., 
in  1  of  Eshner's  cases  the  mother 
was  obese.  In  a  few  instances  adiposis 
dolorosa  has  been  observed  in  members 
of  the  same  family.  Thus,  Cheevers 
reported  the  case  of  a  man  whose 
father  and  sister  both  had  the  dis- 
ease, while  Hammond  reported  2  cases 
occurring  among  sisters.  The  striking 
fact  in  the  etiology  is  the  predominance 
of  the  female  sex ;  the  ratio  is  about  6 
women  to  1  man.  The  age  at  which 
the  disease  makes  its  appearance  is 
exceedingly  variable.  The  youngest  re- 
corded case,  that  of  Hale  White,  began 
at  12  years  of  age;  the  oldest  case 
recorded  was  78  years  of  age.  Ac- 
cording to  Frankenheimer,  the  major- 
ity of  cases   in   men  occur  between 


30    and    40    years    of    age,    and    in 
women    between    30    and    50    years. 

The  disease  was  originally  believed 
to  occur  exclusively  in  women  and 
about  the  climacteric  period ;  although 
this  was  the  rule  in  the  writer's  experi- 
ence, he  has  known  it  to  begin  as  early 
as  12,  and  has  seen  3  cases  in  males. 
He  describes  in  detail  5  cases  of  the 
affection,  4  in  women  whose  ages  range 
from  20  to  42,  and  1  in  a  man  aged 
47.  These  cases  all  presented  the  char- 
acteristic symptoms  of  the  disease.  The 
panniculus  adiposus  was  invariably 
thickened,  sometimes  to  a  marked  ex- 
tent. The  skin  was  red  and  in  depend- 
ent parts  has  a  bluish,  livid  appearance. 
It  was  painful,  sometimes  with  a  feel- 
ing of  burning,  at  other  times  as  if  it 
were  being  pierced  by  a  needle.  The 
skin  of  the  legs  especially,  but  occasion- 
ally that  of  the  trunk  and  arms  also, 
was  thick  and  infiltrated,  generally  in 
patches,  but  in  some  cases  in  large  areas 
involving  the  whole  lower  extremity 
except  the  feet.  The  latter  condition  is 
described  by  the  writer  as  "elephan- 
tiasic  edema."  Actual  edema  was  not 
present,  the  skin  did  not  pit  on  pressure, 
and  no  fluid  was  obtained  on  punctur- 
ing with  a  needle.  Charcot  observed 
this  condition  in  connection  with  indi- 
viduals suffering  from  functional  dis- 
turbances of  the  nervous  system,  and 
named  it  "oedeme  hysterique."  Strub- 
ing  (Archiv  f.  Dermat.  u.  Syphil.,  Feb., 
1902). 

Case  of  adiposis  dolorosa,  or  Der- 
cum's  disease,  believed  to  be  unique,  in 
a  newborn  infant.  The  writer  was 
called  in  consultation  to  see  the  child 
on  the  day  after  its  birth.  It  was  then 
5  weeks  old,  and,  in  addition  to  the 
characteristic  irregular  symmetrical  de- 
posits of  fat,  which  were  situated  on 
the  upper  half  of  the  body  (the  lower 
extremities  being  normal),  there  were 
two  cystic  formations  of  considerable 
size,  one  on  the  left  posterior  aspect  of 
the  neck  and  the  other  on  the  left 
breast.  While  lying  undisturbed  the 
child  appeared  to  be  entirely  comfort- 
able, but  the  slightest  movement  was 
attended    with    pain.     W.    C.    Walser 


422 


ADIPOSIS    DOLOROSA    (DERCUM). 


(Boston    Med.    and    Surg.    Jour.,    June 
30,   1910). 

Occasionally  the  patient  presents  a 
history  of  antecedent  alcoholism  or  of 
syphilis.  As  Price  says,  the  toxic  ef- 
fects of  alcoholism  and  syphilis  are  well 
known  and  the  fact  that  they  frequently 
cause  degenerative  changes  in  the  duct- 
less glands  has  been  emphasized  by 
Lorand,  This  is  suggestive  when  we 
learn  of  the  role  which  the  ductless 
glands  appear  to  play  in  adiposis  dolo- 
rosa. In  a  case  described  by  E.  W. 
Taylor,  the  disease  developed  while  the 
patient  was  convalescing  from  an  acute 
alcoholic  neuritis.  In  quite  a  number 
of  cases  excessive  menstrual  flow  and 
even  uterine  hemorrhages  have  been 
noted.  In  one  case,  that  of  Spiller,  the 
adiposis  dolorosa  followed  pregnancy, 
while  in  another,  that  of  Schlesinger,  it 
followed  an  abortion.  Quite  a  number 
of  cases  finally  have  developed  after 
the  menopause. 

Occasionally  trauma  is  noted  in  the 
history,  and  the  importance  of  this  fact 
has  been  especially  insisted  upon  by 
Guidiceandrea.  In  a  case  of  the  writer's 
and  in  one  of  Eshner's,  trauma  seemed 
to  be  the  direct  exciting  cause.  Emo- 
tional shock  has  also  preceded  the 
onset,  as  in  the  case  of.  Achard  and 
Laubry.  In  Vitaut's  case  there  ap- 
peared to  be  a  mild  infection  of  the 
digestive  tract;  in  other  cases  exposure 
to  cold  and  dampness,  rheumatism, 
appeared  to  play  a  role.  Occasionally 
also  some  other  neurosis  exists  side  by 
side  with  the  affection,  as  in  the  woman 
reported  by  Henry  and  in  a  man  re- 
ported by  the  writer,  both  of  whom 
sufifered  from  epilepsy.  In  other  cases 
again,  undoubted  mental  disease  has 
been  noted ;  sometimes  indeed,  as  in  one 
of  Eshner's  cases,  commitment  to  an 
institution  becomes  necessary. 


Heredity  seems  to  play  some  role, 
the  ancestors  frequently  having  been 
obese,  gouty,  asthmatic,  or  subject  to 
migraine;  in  other  words,  the  victims 
of  nutritional  disturbances.  The  signs 
of  premature  senility  are  frequently 
present.  M.  Gilbert  Ballet  (Presse 
med.,  April  8,  1903). 

Case  of  adiposis  dolorosa  in  a  woman 
aged  80,  the  mother  of  5  children,  who 
had  fallen  fifteen  years  before,  after 
which  accident  an  operation  was  per- 
formed upon  her  hip,  some  bloody  fluid 
being  evacuated.  Since  that  time  her  legs 
have  been  weak.  For  three  years  after- 
ward, and  off  and  on  since,  to  her  65th 
year,  irregular  metrorrhagia  existed. 
Pain  appeared  in  the  left  hip  and  lum- 
bar region,  always  along  the  nerves.  It 
is  made  worse  by  pressure.  She  grew 
stouter  very  gradually,  weighing  now 
163  pounds,  while  she  is  under  5  feet 
high.  The  fat  is  in  large  masses  about 
the  malleoli,  hips,  calves,  buttocks,  ab- 
domen, forearms,  and  backs  of  the 
arms  especially.  This  fat  is  only  found 
in  certain  regions,  and  is  not  universally 
or  equally  distributed.  Debove  (Presse 
med.,  July  17,  1901). 

Case  in  a  woman,  aged  61  years,  who, 
with  an  apparently  unimportant  family 
history,  dates  her  troubles  from  a  fall 
from  a  chair  many  years  before  the 
disease  became  manifest.  The  left  eye 
became  blind,  and  the  left  side  of  the 
nose  developed  a  tumor.  The  adiposis 
appeared  in  her  thirtieth  year  in  the 
right  leg  first,  and  then  in  the  left. 
The  arms  were  next  attacked.  Pain 
accompanied  all  the  early  symptoms. 
When  examined,  the  patient's  neck  and 
the  subclavicular  region,  as  well  as  the 
abdomen,  besides  the  limbs,  were  loaded 
with  fat.  An  enormous  fatty  tumor 
was  also  present  on  the  internal  aspect 
of  the  left  thigh.  The  buttocks  were 
immense.  The  pores  of  the  skin  were 
enlarged.  Pain,  lasting  two  or  three 
days,  in  the  fatty  region  was  not  un- 
common. Sensation  and  temperature 
were  normal ;  the  corneal  reflex  was 
absent,  as  well  as  the  patellar  and 
Achilles.  Mentality  was  apparently 
normal,  but  there  was  great  asthenia, 
increasing   with   age.     In  view   of   the 


ADIPOSIS    D(3LOROSA    (DERCUM). 


423 


eye  trouble  and  the  nasal  tumor,  the 
writers  are  inclined  to  attribute  the 
etiology  of  the  disease  to  some  affection 
of  the  pituitary  body.  Delucq  and 
Alaux  (Presse  med.,  Sept.  17,  1904). 

PATHOLOGY.— Up  to  the  time 
of  writing,  eight  autopsies  have  been 
held.  These  indicate  that  in  adiposis 
dolorosa  there  is  some  disturbance  of 
the  internal  secretions,  excessive  forma- 
tion of  fatty  tissue,  and  an  interstitial 
neuritis  of  the  nerve-fibers  contained  in 
the  deposits. 

[Price  has  summarized  the  results  of  the 
various  autopsies  as   follows : — 

Cases  I  and  II. — Dcrcum :  Macroscopic 
disease  of  the  thyroid,  the  glands  being  en- 
larged and  the  seat  of  calcareous  infiltration. 

Case  III. — Dercum :  Irregular  atrophy  of 
the  thyroid,  extensive  interstitial  neuritis  of 
peripheral  nerves  in  fatty  deposits,  degenera- 
tion in  the  columns  of  Coll. 

Case  IV. — Burr :  Glioma  of  the  pituitary 
body;  colloid  degeneration,  with  atrophy 
and  absence  of  secreting  cells  in  many  acini 
of  the  thyroid  gland;  interstitial  neuritis  of 
terminal  filaments;    sclerotic  ovaries. 

Case  V. — Dercum  and  McCarthy :  Adeno- 
carcinoma of  pituitary  body,  thyroid  nor- 
mal, right  suprarenal  gland  hypertrophied, 
hemolymph-glands,  interstitial  neuritis,  un- 
developed testicles. 

Case  VI. — Guillain  and  Alquier:  Hypoph- 
ysis doubled  in  size,  with  marked  increase 
of  connective  tissue  in  the  glandular  portion 
and  changes  suggesting  an  alveolar  carci- 
noma ;  thyroid  hypertrophied,  with  increase 
in  connective-tissue   stroma. 

Case  VII. — Price :  Inflammatory  changes 
in  thyroid,  with  marked  increase  in  the  inter- 
stitial connective  tissue,  one  whole  lobe  being 
especially  infiltrated,  the  other  showing 
compensatory  hypertrophy.  Inflammatory 
changes  in  hypophysis,  with  presence  of  a 
condition  suggesting  alveolar  or  glandular 
carcinoma,  interstitial  and  parenchymatous 
neuritis,  sclerotic  ovaries. 

Case  VIII. — Price :  Marked  nicrease  in 
the  connective  tissue  of  the  thyroid  gland, 
dilatation  of  the  acini,  with  infoldings  of  the 
cuboidal  epithelial  lining.  The  same  changes 
in  the  hypophysis  as  were  found  in  Cases  VI 


and  VII,  but  less  marked.     No  abnormalities 
of  the  adipose  tissue.     F.  X.  Dercum.] 

Delecq  thinks  that  disease  of  the 
thyroid,  testicle,  ovary,  and  pituitary 
body  may  -be  causes  of  adiposis 
dolorosa.  Von  Schroeter  concludes 
that  adiposis  dolorosa  is  due  to  a 
dysthyroidismus.  Pineles  regards 
the  disease  as  a  result  of  the  disturb- 
ance of  function  in  numerous  blood- 
glands  and  that  there  are  present 
hypothyroidism,  genital  atrophy,  and 
changes  in  the  hypophysis. 

The  thyroid  gland,  it  will  be  noted, 
showed  unmistakable  changes  in  7  of 
the  8  autopsies.  These  changes  are 
very  interesting  and  are  well  illus- 
trated by  the  findings  in  the  third 
autopsy  of  the  writer,  in  which  the 
gland  was  submitted  to  microscopic 
examination.  A  study  of  the  sections 
reveals  the  gland  to  be  made  up  of 
three  or  four  different  kinds  of  secret- 
ing tissue.  In  the  first  place,  there 
are  large  acini  distended  by  colloid 
material.  These  large  acini  vary  in 
size,  and  their  contents  vary  also  in 
density.  The  larger  acini  are  globu- 
lar in  shape,  while  some  of  the 
smaller  ones  are  elongated  or  angular 
in  form.  The  limits  of  these  acini  are 
clearly  indicated  by  blood-vessels 
which  occupy  their  walls.  The  epi- 
thelium is  a  single  layer,  which  covers 
uniformly  the  peripheries  of  the 
acini.  Contrasted  with  these  there  is 
another  kind  of  secreting  tissue, 
which  is  very  solid,  and  in  which  the 
acini  are  made  out  with  great  diffi- 
culty. They  consist  of  cells  filling 
interspaces  of  the  stroma,  and  the 
blood-vessels  supplying  these  acini 
can  only  be  made  out  in  exceptional 
instances.  The  lumina  of  these  acini 
when  they  can  be  made  out  are 
usually  very  small.     There  is  he-re  a 


424 


ADIPOSIS    DOLOROSA    (DERCUM). 


complete  absence  of  colloid  material. 
In  other  portions  acini  are  observed 
which  are  a  transition  between  the 
more  solid  nests  of  cells  and  the  large 
vesicles  which  contain  the  colloid 
material.  In  addition,  there  is  a  third 
form  of  acinus,  which  is  of  peculiar 
interest  in  that  the  acini  present  plica- 
tions or  papillary  outgrowths  of  the 
walls.  These  plications  .,  or  out- 
growths project  into  the  lumina  of 
the  affected  acini,  which  contain,  as 
a  rule,  colloid  material  of  lighter 
staining  qualities  than  the  larger 
vesicles,  although  not  lighter  than  is 
contained  in  some  of  the  smaller 
vesicles.  The  epithelium  of  these 
last-mentioned  acini  appears  at  times 
to  be  slightly  higher  than  the  normal 
cubical  epithelium  of  the  other  vesi- 
cles. Finally,-^  in  some  areas,  solid 
masses  of  cells  resembling  lymphoid 
cells  are  seen,  but  these  are  probably 
young  solid  acini,  like  the  small  acini 
described  above,  though  the  limits  of 
these  acini  are  irregular,  because  of 
the  absence  of  preserved  blood  in 
the  surrounding  vessels  and  of  the 
absence  of  definite  interstitial  frame- 
work. 

The  changes  observed  are  indica- 
tive in  part  of  hypertrophy.  Certainly 
this  seems  to  be  the  only  interpreta- 
tion which  can  be  placed  on  the 
numerous  small  acini  which  appear 
to  be  in  process  of  development. 
Whether  the  large  acini,  distended 
with  more  deeply  staining  colloid 
material,  are  to  be  considered  old 
acini,  containing  old  or  altered  colloid 
material,  it  is,  of  course,  impossible 
to  say,  but  such  an  interpretation 
does  not  seem  improbable.  The  pli- 
cations and  papillary  outgrowths 
observed  in  some  of  the  acini  are 
also  worthy  of  comment,  in  that  they 


evidently  represent  an  attempt  to  in- 
crease the  secreting  surface  of  the 
acini  and  are  again  expressive  of 
h3^pertrophy. 

These  findings  are  very  surprising, 
and  it  is  difficult,  of  course,  to  frame  an 
explanation.  It  is  not  impossible  that 
we  have  here  a  hypertrophy  which  is 
the  direct  outcome  of  a  general  atrophy 
of  the  gland;  in  other  words,  a  com- 
pensatory hypertrophy  such  as  Hal- 
stead  obtained  in  the  dog  after  partial 
extirpation.  The  gland  was  small,  per- 
haps sufficiently  so  to  determine  com- 
pensatory hypertrophy.  It  is  probable, 
however,  that  other  factors,  e.g.,  quali- 
tative changes  of  function,  also  played 
a  role  in  the  peculiar  symptoms  from, 
which  this  patient  suffered.  It  is  not 
inconceivable  that  as  a  result  of  de- 
ranged thyroid  action  some  substance 
was  thrown  into  the  circulation,  which 
at  one  and  the  same  time  prevented  the 
proper  oxidation  of  the  hydrocarbons 
of  the  food  and  tissues,  and  also  acted 
as  a  cause  of  neuritis  and  nerve  degen- 
eration. Whatever  the  explanation,  it 
is  interesting  to  recall  the  diminished 
sweating  and  the  occasional  slowness  of 
speech  and  mental  irritability.  The  in- 
terpretation is  somewhat  difficult ;  the 
obesity  and  the  dryness  of  skin  suggest 
thyroid  deficiency,  while  the  flushing 
of  the  face,  the  occasional  tachycardia, 
and  the  psychic  symptoms  would  point 
rather  to  thyroid  excess,  and  it  is  safer 
perhaps  with  Pineles  to  regard  the  con- 
dition as  one  of  dysthyroidismus. 

Among  the  most  significant  findings, 
however,  are  the  changes  noted  in  the 
pituitary  body.  In  5  of  the  6  cases  in 
which  the  pituitary  was  examined,  it 
was  found  diseased.  Thus  Burr  de- 
scribed a  glioma  of  the  pituitary,  Der- 
cum  and  McCarthy  adenocarcinoma, 
Guillain  and  Alquier  changes  suggest- 


ADIPOSIS   DOLOROSA   (DERCUM). 


425 


ing  an  alveolar  carcinoma  and  Price 
changes  likewise  suggesting  alveolar  or 
glandular  carcinoma  in  2  cases.  The 
detailed  findings  in  the  case  of  Dercum 
and  McCarthy  are  ver}^  interesting. 

The  pituitary  bod}^  was  closely  ad- 
herent to  the  dural  lining  of  the  sella 
turcica,  and  an  attempt  at  removal  of 
the  gland  revealed  a  calcareous  layer 
from  1  to  3  mm.  in  thickness,  be- 
tween the  dura  and  the  gland  sub- 
stance. When  this  was  removed,  what 
appeared  to  be  the  normal  portion  of 
the  gland  occupied  the  left  quarter  of 
the  mass ;  the  remaining  three-fourths 
consisted  of  a  tumor  mass.  It  was  of 
the  same  consistence  as  the  gland  struc- 
ture, roughened  on  the  surface  where 
the  calcareous  plate  had  been  removed, 
and  attached  at  its  farthest  end  to  the 
internal  carotid  artery. 

The  calcareous  plate  under  the 
microscope  showed  a  true  bone  reticu- 
lum infiltrated  with  the  eosinophilic 
cells  comprising  the  tumor  mass.  Sec- 
tions were  made  transversely  through 
the  gland  and  tumor.  The  tumor  mass 
was  composed  almost  entirely  of  the 
eosinophilic  type  of  cells,  arranged 
irregularly,  with  a  minimal  amount  of 
interstitial  tissue.  Around  the  pe- 
riphery of  the  tumor  mass  the  cells 
w^ere  arranged  in  parallel  rows,  much 
after  the  type  of  cell  arrangement  seen 
in  endotheliomata.  The  tumor  mass 
had,  on  account  of  the  arrangement  of 
the  cells  in  rows  at  its  periphery,  an 
appearance  as  if  it  were  encapsulated 
and  separated  from  the  normal  gland 
tissue.  A  careful  study  of  the  cells  of 
the  tumor  revealed  no  trace  of  a  regu- 
lar arrangement  of  the  cells,  such  as  is 
seen  in  the  acini  of  the  normal  gland. 
The  individual  cells  were  round,  stained 
a  pinkish  red  with  eosin,  and  contained 
a  small,  deeply  staining  nucleus.     The 


nucleus  in  some  of  the  larger  cells  was 
very  large  and  irregular  in  shape,  such 
as  is  frequently  seen  in  proliferating 
cells.  The  cells  varied  greatly  in  size : 
some  were  twice  the  size  of  the  normal 
gland  cells;  others  one-third  to  one- 
fourth  that  size.  Between  these  cells, 
and  at  times  in  the  capillary  vessels  of 
the  tumor  mass,  small  areas  of  colloid 
material  were  seen. 

The  area  of  normal  gland  tissue — 
i.e.,  arranged  according  to  the  normal 
gland  structure — is  about  one-third  the 
size  of  the  normal  adult  gland,  and  is 
situated  between  the  tumor  mass  and 
the  protuberance,  consisting  of  cerebral 
tissue.  The  larger  portion  of  the 
glandular  acini  is  perfectly  normal. 
At  the  junction  of  the  latter  with  the 
nerve  tissue,  and  extending  into  the 
latter  area,  are  large  groups  of  cells, 
following  an  alveolar  arrangement  and 
differing  "from  the  rest  of  the  section 
by  the  deep  staining  properties  of  the 
cells  with  nuclear  stains.  The  posterior 
portion  of  the  gland,  composed  of 
reticular  nerve  tissue,  is  permeated  by 
the  small,  round,  deeply  staining  nuclei 
in  such  a  way  as  to  give  the  impression 
that  the  infiltrating  process  followed 
definite  lymph-channels.  At  the  pe- 
riphery of  the  acinous  portion  of  the 
gland,  masses  of  colloid  material,  of 
sufficient  size  to  be  visible  to  the  naked 
eye  as  minute  dots,  are  inclosed  in 
areas  lined  by  rounded  cells.  The 
tumor  mass,  composed  as  it  is  of  the 
same  type  of  cells  as  make  up  the 
acinous  portion  of  the  gland,  must 
necessarily  belong  to  the  carcinomata. 
The  infiltrating  tumor  formation,  begin- 
ning in  the  acinous  portion  of  the  gland 
and  involving  the  cerebral  portion  of  the 
gland,  follows  the  cell  arrangement  of  an 
adenocarcinoma.  The  arrangement  of 
the  eosinophile  cells  of  the  tumor  mass 


426 


ADIPOSIS    DOLOROSA    (DERCUM). 


around  the  periphery  of  the  tumor 
resembles  an  endothelioma,  but  the  type 
of  cell  points  strongly  to  a  diagnosis  of 
carcinoma. 

In  commenting  upon  the  involvement 
of  the  pituitary  in  the  above  instance, 
the  writers  pointed  out,  that  bearing 
in  mind  the  interrelation  which  exists 
between  the  thyroid  gland  and  the 
pituitary  body,  the  pituitary  body  is 
thus  brought  into  relation,  though  per- 
haps indirectly,  with  a  fat-producing 
or  fat-destroying  function — a  relation 
which,  up  to  that  time,  had  not  been 
considered.  In  the  light  of  recent 
observations  this  subject  assumes  a 
new  importance.  Froelich  has  shown 
that,  instead  of  the  symptom-complex 
termed  acromegaly,  lesions  of  the 'hy- 
pophysis may  be  associated  with  an 
adipositas  universalis  and  genital  atro- 
phy. In  other  words,  hypopituitarism, 
other  things  equal,  leads  to  adipositas. 
Further  curious  and  remarkable  inter- 
relations of  function — seemingly  anti- 
thetical— appear  to  exist  between  the 
pituitary  and  the  pineal  gland, — the 
pineal  gland  appearing  to  have  a  fat- 
producing  and  a  fat-destroying  func- 
tion inversely  to  the  pituitary.  For  a 
detailed  presentation  of  the  subject, 
which  here  would  lead  us  too  far  afield, 
the  reader  is  referred  to  Otto  Mar- 
burg's interestmg  paper  on  "Adipositas 
Cerebralis,'  a  Contribution  to  our 
Knowledge  of  the  Pathology  of  the 
Pineal  Gland,"  Deutsche  Zeitschrift  f iir 
Nervenheilkunde,  1908,  Bd.  36,  p.  114. 

In  his  discussion  of  the  pathology 
of  adiposis  dolorosa.  Price  points  out 
that  sufficient  attention  has  not  been 
given  the  pituitary,  which,  he  suggests, 
is  etiologically  of  almost  as  much  im- 
portance as  the  thyroid.  It  would  ap- 
pear, indeed,  from  the  above  considera- 
tions that  the  pituitary  must  be  seriously 


considered,  and  he  asks  the  question 
whether  the  symptom  of  adiposis  dolo- 
rosa may  not  result  from  primary  dis- 
ease of  either  the  pituitary  or  the 
thyroid  gland.  It  is  well  known  that  a 
close  interrelation  exists  between  these 
two  glands;  experimental  extirpation 
of  the  thyroid  in  animals  has  been 
found  to  be  followed  by  pituitary  en- 
largement and  it  would  seem  that  dis- 
ease of  one  gland  means  sooner  or  later 
disease  of  the  other.  Poirier  also  di- 
rects especial  attention  to  the  hypophy- 
sis, which  he  evidently  regards  as  the 
most  important  structure  concerned  in 
adiposis  dolorosa. 

An  examination  of  the  fatty  deposits 
reveals  not  only  the  structure  of  fatty 
tissue,  but  also  the  signs  of  great  nutri- 
tional activity.  Fragments  removed 
during  life  by  the  Duchenne  trocar  in 
the  writer's  first  case  and  submitted  to 
microscopical  examination  presented  the 
appearance  of  a  connective  tissue  em- 
bryonal in  type.  The  cells  were  volum- 
inous, fusiform  and  containing  large 
nuclei,  while  the  intercellular  spaces 
were  filled  by  a  transparent  substance 
apparently  without  structure.  On  the 
whole  the  appearance  was  that  of  a 
lymphoid  tissue.  In  some  fragments 
fat  cells  were  numerous  and  among 
these  were  cells  which  evidently  had  not 
undergone  complete  fatty  transforma- 
tion. In  some  of  them  the  nuclei  were 
still  very  apparent,  while  osmic  acid 
revealed  fat  drops  suspended  in  the  cell 
contents. 

In  the  autopsy  recorded  by  Dercum 
and  McCarthy,  the  fatty  nodules  were 
submitted  to  microscopical  examination 
with  the  following  result.  Each  of  the 
larger  nodules  was  composed  of  cap- 
sules inclosing  large  numbers  of  small, 
oval,  fatty  bodies  connected  with  each 
other  and  with  the  capsule  by  delicate 


ADIPOSIS    DOLOROSA    (DERCUM). 


427 


fibrous  bands.  Tbese  delicate  trabecnloi 
united  and  joined  tbick,  jelly-like  bands 
attacbed  to  the  capsule.  Sections  made 
tbrougb  the  connective-tissue  capsule 
and  the  fatty  bodies  in  situ  gave  the 
following  structure :  The  capsule  was 
composed  of  several  layers  of  well- 
developed  connective  tissue.  Within 
this  capsule  a  looser  areolar  tissue  is 
met.  This  tissue  is  highly  vascular,  and 
between  the  vessels  is  a  reticular  tissue, 
denser  in  some  areas  than  others  and 
inclosing  a  large  number  of  mono- 
nuclear cells,  a  few  polynuclear  cells, 
and  large  numbers  of  cells  staining  a 
tawny  color  by  the  Van  Gieson  stain. 
Scattered  through  the  granular,  tawny 
masses  many  of  the  mononuclear  type 
of  cells  may  be  found.  In  other  areas 
granules  of  blood-pigment  in  clumps 
may  be  seen.  Wherever  the  connective- 
tissue  trabeculse  penetrate  into  the  con- 
gested fat  nodule,  this  same  fine,  reticu- 
lar structure,  holdin'g  in  its  meshes  rich 
plexuses  of  blood-vessels,  and  between 
these  a  fine  reticulum  of  connective 
tissue  filled  with  a  light-yellow  granular 
material,  with  nucleated  yellow  cells, 
small  mononuclear  cells,  polynuclear 
reagents,  as  do  nucleated  red  blood- 
cells,  and  numbers  of  degenerating  red 
blood-cells,  may  be  seen.  Some  of 
these  cells  react  to  many  of  the  staining 
corpuscles,  but  to  the  Biondi-Ehrlich 
triple  stain  they  appear  more  as  mono- 
nuclear leucocytes.  This  tissue  is  iden- 
tical in  structure  with  the  hemolymph- 
glands  found  in  the  immediate  neigh- 
borhood of  the  large,  congested  nodules 
of  subcutaneous  fat. 

Lying  loose  in  the  yellow  fat,  several 
small,  firm  bodies,  the  size  of  a  split 
pea  and  of  a  yellowish-brown  color, 
\vere  found.  These  proved  on  micro- 
scopic examination  to  be  hemolymph- 
glands.    They  were  composed  of  a  cap- 


sule of  connective  tissue,  from  which 
trabecul?e  of  connective  tissue  spread 
in  many  dififerent  directions  throughout 
the  body.  Within  this  trabecular  net- 
work a  rich  plexus  of  capillaries  was 
found.  Between  the  capillaries  a  fine 
meshwork  of  fibers  contains  large  num- 
bers of  lymphoid  cells,  with  here  and 
there  groups  of  red  blood-corpuscles. 
Free  blood-pigment  giving  the  iron  re- 
action was  found  in  small  quantities 
free   in   the   trabecular   network.      The 


Fatty  nodtile  dissected  from  subcutaneous  fat; 
shows  the  encapsulation  of  the  fat,  with  nerve- 
fibers  branching  over  it.    (Dercum  and  McCarthy.) 

Opinion  of  Dr.  Simon  Flexner  that 
these  structures  are  new-formed  hemo- 
tymph-glands  was  confirmed  by  that  of 
Dr.  A.  S.  Warthin,  of  Ann  Arbor,  who 
has  written  on  the  subject. 

An  examination  of  the  nerves  found 
in  the  fat  has  shown  the  presence  of  an 
interstitial  neuritis.  There  is  a  diminu- 
tion of  nerve-fibers,  together  with  a 
marked  proliferation  of  the  perineu- 
rium and  endoneurium,  (See  illustra- 
tion, next  page.) 

The  chemistry  of  the  subcutaneous 
fat  was  investigated  by  Edsall,  who 
especially  sought  for  an  increase  in 
the  fatty  acids  as  this  might  have  had 
to  do  with  the  pain  and  tenderness. 


428 


ADIPOSIS    DOLOROSA    (DERCUM). 


However,  marked  free  acidity  was  not 
present.  Its  amount  was  rather  low, 
lowest  of  all  in  the  tumor  fat,  and 
decidedly  below  that  of  normal  fat. 
The  significance  of  this  fact  is  not 
evident. 

Case  in  which  there  concurred  adipo- 
sis dolorosa  with  well-marked  myxe- 
dematous manifestations.  In  view  of 
the  frequency  of  myxedematous  symp- 


Section  of  nerve  in  subcutaneous  fat  nodule 
showing  intersititial  neuritis.  A  distinct  over- 
growth of  connective  tissue  is  present  between 
the  nerve-fibers.  The  number  of  blood-vessels 
is  also  increased  over  normal  nerve-tissue.  {Der- 
cum  and  McCarthy.) 

toms  in  adiposis  dolorosa,  we  are  justi- 
fied in  accepting  a  kindred  cause  of 
both  syndromes.  That  thyroid  insuffi- 
ciency stands  at  the  foundation  of 
myxedema  there  can  be  little  doubt; 
again,  some  thyroid  alteration  was 
found  in  4  out  of  5  cases  of  adiposis 
dolorosa  which  came  to  autopsy.  While 
the  seat  of  the  externally  visible  pa- 
thognomonic symptoms  of  myxedema 
is  in  the  subcutaneous  tissues,  that  of 
adiposis  dolorosa  is  situated  in  the 
fatty  structures. 


Moreover,  the  improvement  of  case 
reported  following  the  administration 
of  thyroid  extract  seems  to  evince  with 
certainty  that  perverse  thyroid  function 
was,  to  say  the  least,  an  antecedent. 
The  yielding  of  both  symptom-com- 
plexes to  the  same  medication  again 
points  to  their  interrelation  or  their 
springing  from  a  kindred  cause.  Thy- 
roid therapy  cannot,  therefore,  be  util- 
ized as  a  test  of  differentiation  between 
myxedema  and  adiposis  dolorosa,  as 
some  authors  maintain,  because  both 
syndromes  may  vanish  under  its  in- 
fluence, and,  as  in  the  present  instance, 
even  at  the  same  time.  In  so  far  as 
the  pains  disappeared  in  the  ratio  of 
shrinkage  of  the  fat  bunches,  we  are 
justified  in  concluding  that  the  irrita- 
tion of  the  nerve  terminals  was  either 
due  to  mechanical  insults  on  the  part  of 
the  overgrowth  of  fat-tissue  or  to  cer- 
tain fatty  acids  or  products  of  catab- 
olism  exciting  the  nerve  trunks  in  the 
vicinity  of  the  fat  deposits  and  stimu- 
lating the  fat-tissue  to  further  prolifer- 
ation. In  view  of  the  fact  that  myxe- 
dema occurs  without  pains  in  the  swell- 
ings, it  appears  that  thyroid  insufficiency 
cannot  be  held  directly  responsible  for 
the  aches  and  paroxysms  in  adiposis 
dolorosa.  Heinrich  Stern  (Amer.  Jour. 
Med.  Sci.,  March,  1910). 

DIAGNOSIS.— The  diagnosis  is 
based  upon  the  presence  of  the  fatty 
masses,  presenting  the  feature  of 
pain,  spontaneous,  paroxysmal,  or 
elicited  by  manipulation,  and  having 
in  addition  the  physical  peculiarities 
already  described.  The  disease  is 
readily  differentiated  from  myxedema 
because  of  non-involvement  of  the 
face  and  hands  and  because  of  the 
absence  of  pain  in  myxedema.  When 
the  tumor  masses  are  numerous  and 
small,  they  might  suggest  neurofi- 
bromatosis, but  the  peculiar  charac- 
ter of  the  swellings,  the  fact  that 
they  appear  Icbulated  under  palpa- 
tion, that  they  are  spontaneously 
painful  and  almost  never  occur  upon 


ADIPOSIS    DOLOROSA    (DERCUM). 


429 


the  face  or  hands  would  serve  to 
make  the  differentiation. 

In  neurofibromatosis,  again,  there 
are  two  kinds  of  tumors,  some  of 
them  cutaneous,  not  rarely  on  the 
face,  and  others  on  the  mucous  sur- 
faces. They  are  of  soft,  yielding  con- 
sistence and  very  slightly  painful. 
Others,  those  of  nervous  origin,  are 
small,  very  hard,  and  often  grouped 
along  the  course  of  the  nerve  trunks 
like  a  string  of  beads.  They  are 
only  laterally  mobile,  while  the  adi- 
pose tumors  are  mobile  in  all  direc- 
tions and  are  irregularly  distributed. 
Again,  anomalies  of  pigmentation  are 
rare  in  adiposis  dolorosa,  but  are 
frequent  and  sometimes  very  pro- 
nounced in  neurofibromatosis.  On 
the  whole,  it  is  hardly  probable  that 
an  error  could  be  made. 

In  simple  obesity,  the  fat  is  dis- 
tributed throughout  all  the  tissues 
and  does  not  heap  itself  up  in  separate 
lipomatous  masses,  such  as  is  the  case 
in  adiposis  dolorosa, — even  in  the  so- 
called  diffuse  form.  Besides,  ordinary 
obesity  is  painless  and  is  a  matter  of 
gradual  development,  while  the  fatty 
deposit  in  adiposis  dolorosa  is  painful 
and  occurs  as  the  result  of  successive 
crises. 

PROGNOSIS.— Adiposis  dolorosa 
is  an  affection  which  is  essentially 
chronic.  Most  cases  live  for  many 
years  and  it  does  not  appear  to  imme- 
diately threaten  life.  However,  in 
cases  of  long  standing,  a  bed-ridden 
period  eventually  ensues ;  general 
exhaustion  becomes  more  and  more 
marked;  degeneration  and  failure  of 
the  heart  muscle,  pulmonary  conges- 
tion, or  a  renal  complication  may 
terminate  the  picture.  The  resistance 
to  infection  also  appears  to  be  greatly 
diminished,   for   one    of   the   writer's 


cases  died  very  rapidly  of  an  attack 
of  erysipelas. 

Cases  in  a  relatively  early  stage 
of  development — more  particularly 
cases  with  small  nodular  or  localized 
and  limited  deposits — offer  a  dis- 
tinctly better  prognosis  and  are  dis- 
tinctly amenable  to  improvement. 
Advanced  cases,  cases  with  very  ex- 
tensive deposits,  marked  asthenia,  and 
especially  with  the  tendency  to  sub- 
cutaneous hemorrhages  and  hemor- 
rhages from  the  mucous  membranes 
are  very  unpromising. 

TREATMENT.— In  the  treatment 
of  adiposis  dolorosa  one  remedy  has 
in  a  few  cases  proved  of  value  and 
that  is  thyroid  substance.  This 
should  be  given  in  doses  of  from  2)^ 
to  5  grains  three  times  daily,  for  a 
very  long  time.  The*  salicylates, 
notably  aspirin,  are  of  decided  value 
in  relieving  the  pain.  The  best  plan 
of  procedure,  as  a  matter  of  course, 
is  to  place  the  patient  in  bed,  and  to 
institute  a  systematic  course  of  treat- 
ment. The  rest  should  be  absolute 
and  should  extend  over  several 
months  of  time. 

Typical  case  with  symptoms  of  myxe- 
dema in  which  the  treatment  consisted 
of  an  antiobesity  diet,  thyroid  medica- 
tion, and  physical  therapeutics,  especially 
vibratory  massage  and  exercise.  Nine 
months  later  the  patient  presented  her- 
self to  show  the  beneficial  effects  of 
the  treatment.  Excepting  the  pallor, 
which,  she  said,  had  always  caused  her 
much  annoyance  since  her  early  youth, 
she  looked  very  well.  She  felt  strong, 
and  was  able  t-  walk  from  five  to  eight 
miles  a  day;  she  experienced  no  short- 
ness of  breath  on  ordinary  exercise, 
but  perspired  mildly  when  she  walked 
briskly.  ■  The  fat  Lrnches  had  disap- 
peared almost  entirely ;  the  neuralgic 
pains  had  ceased  about  four  months 
earlier ;  there  was  no  tenderness  on 
pressure  on  the  location  of  the  former 


430 


ADIPOSIS    DOLOROSA    (DERCUM). 


fat  masses.  The  skin  in  the  supraclavic- 
ular regions  and  in  the  face  had  been 
quite  tender.  She  evinced  not  the 
slightest  mental  depression  and  apathy, 
but,  on  the  contrary,  displayed  a  healthy 
optimism.  Her  weight  had  been  re- 
duced to  161  pounds.  Heinrich  Stern 
(Amer.  Jour.  Med.  Sci.,  March,  1910). 

The  patient  should  be  weighed 
when  treatment  is  begun  and  thyroid 
substance  given  at  first  in  small  and 
then  in  somewhat  larger  doses.  At 
the  same  time  a  diet  should  be  insti- 
tuted that  is  largely  free  from  carbo- 
hydrates and  fats.  It  should  be 
remembered,  however,  that  a  diet,  no 
matter  how  rigid,  will  of  itself  make 
no  impression  in  adiposis  dolorosa ; 
it  will  fail  absolutely.  It  is  of  course 
wise  to  institute  a  careful  diet,  but 
patients  do  better  when  the  diet  is 
not  too  strict.  Inasmuch  as  the  affec- 
tion is  attended  by  a  marked  asthenia, 
the  diet  should  be  nutritious.  It 
should  consist  of  the  red  meats  in 
moderation,  the  white  meats  freely, 
the  succulent  vegetables,  eggs,  and 
skimmed  milk.  The  latter  can  be 
used  between  meals  and  if  necessary 
also  at  mealtimes. 

The  pains  are  not  infrequently 
controlled  or  at  least  made  better  by 
aspirin  or  salophen  in  full  doses,  10 
or  15  grains  three  times  daily  after 
meals.  Sometimes  the  tenderness 
and  soreness  are  better  borne  when 
the  limb  or  part  affected  is  gently 
supported  by  a  flannel  roller;  if  the 
tenderness  be  extreme  a  layer  of 
cotton-wool  may  first  be  applied. 

Just  as  soon  as  the  tenderness 
permits,  gentle  massage  should  be  in- 
stituted; sometimes  this  can  never 
be  employed ;  in  other  cases  again  it 
can  be  instituted  comparatively  early 
and  there  can  be  no  doubt  that  in  a 
measure   it    favors   the    diminution   of 


the  swellings,  especially  if  the  patient 
can  bear  deep  kneading.  Bathing 
between  blankets  as  in  ordinary  rest 
treatment  should  also  be  carried  out, 
but  of  themselves  baths  accomplish 
nothing  in  adiposis  dolorosa ;  indeed 
the  ph3'^sical  exertion  and  manipula- 
tion attendant  upon  the  application 
of  ordinary  hydrotherapeutic  meas- 
ures in  these  cases  exhausts  the 
patient. 

It  is  a  good  plan  to  keep  a  record 
of  the  pulse  and  temperature  during 
the  thyroid  administration,  although 
the  writer  has  never  observed  any 
fluctuations  of  moment  in  these  cases, 
even  when  the  thyroid  was  pushed. 
The  patient  should,  of  course,  be 
weighed  from  time  to  time  and  the 
dose  of  thyroid  modified  according  to 
the  impression  made.  In  some  cases 
no  impression  whatever  can  be  made; 
in  other  cases  again  the  impression 
is  decided.  In  3  cases  of  the  writer, 
the  result  was  most  satisfactory ;  2  of 
these  were  treated  systematically  by 
rest  in  bed;  the  third  could  not  for 
certain  reasons  be  put  to  bed.  In  all 
3  the  improvement  in  the  size  of  the 
swellings  and  in  the  lessening  of  pain 
was  very  great.  Treatment  was  car- 
ried out  six  months  to  a  year.  In  1 
case  the  affection  recurred  at  the  end 
of  two  years,  but  was  again  con- 
trolled. In  the  second,  improvement 
and  practically  good  health  has  per- 
sisted for  four  years.  The  third  was 
greatly  improved  and  has  disappeared 
from  observation. 

The  experience  of  the  writer  with 
cases  in  the  hospital  wards  and  out- 
patient departments  has  been  very 
unsatisfactory  partly  because  many 
of  the  cases  were  greatly  advanced, 
the  deposits  being  enormous  and  the 
asthenia   grave,    and    partly    because 


ADONIS    VERNALIS    (SAJOUS). 


431 


the  cases  could  not  be  kept  system- 
atically under  treatment  for  a  suffi- 
ciently long  period. 

General  tonics,  iron,  arsenic,  strych- 
nine may  be  given,  but  they  do  not  help 
appreciably.  Electricity  is  useless. 
Finally,  it  would  in  the  judgment  of 
the  writer  be  perfectly  justiliable  to 
attempt  the  surgical  enucleation  of  a 
specially  painful  mass ;  this  procedure 
has  not  yet  been  attempted.  We 
should  bear  in  mind,  of  course,  that 
these  patients  have  but  a  feeble 
resistance  to  shock  and  often  pre- 
sent, even  to  superficial  examination, 
marked  cardiac  weakness. 

F.  X.  Dercum, 

Philadelphia. 

ADIPOSITAS  CEREBRALIS. 

See  Obesity,  Frohlich's  Disease. 

ADNEPHRIN.  See  Animal  Ex- 
tracts :  Adrenals. 

ADONIS  VERNALIS.— Adonis  is 
a  ranunculaceous  plant,  closely  related 
to  the  anemone,  growing  wild  in  Europe, 
Asia,  and  Africa.  Several  species  of 
adonis  are  employed, — Adonis  vernalis, 
A.  (cstivalis,  A.  capensis,  A.  cupaniana, 
and  A.  amiirensis, — but  all  seem  to 
possess  the  same  properties,  although 
the  several  varieties  are  variously  em- 
ployed in  the  different  countries  in 
which  they  grow.  In  Russia,  for  in- 
stance, it  has  long  been  employed  in 
cardiac  diseases,  and  in  Africa  as  a 
substitute  for  cantharides,  the  bruised 
leaves,  when  fresh,  possessing  vesicat- 
ing properties. 

DOSE. — An  infusion  of  4  to  8  parts 
of  the  plant  in  200  of  water  may  be 
given  in  tablespoonful  doses  three  or 
four  times  a  day  (Huchard).  The 
tincture  may  be  administered  in  doses 
of  ^  to  1  dram   (2  to  4  c.c).     The 


lluidextract  has  also  been  used  in 
doses  of  1  to  2  minims  (0.06  to  0.12 
c.c). 

Cervello  isolated  a  glucosid  from 
.Idoiiis  7'cnialis, — adonidin, —  a  yellow, 
liygroscopic  powder  having  a  bitter 
taste,  obtained  from  the  leaves.  It  is 
soluble  in  water  and  alcohol,  ])ut  in- 
sc)lul)le  in  ether  or  chloroform. 
Adonidin  is  administered  in  doses 
varying  from  Yiq  to  ^  grain  (0.004 
to  0.017  Gm.).  It  acts  more  promptly 
than  digitalis. 

Inoko  also  obtained  a  glucosid — 
adonin — from  the  Japanese  plant, 
Adonis  amurcnsis.  This  substance  is 
free  from  nitrogen,  amorphous,  color- 
less, of  a  bitter  taste,  and  soluble  in 
water,  alcohol,  and  chloroform.  The 
effects  observed  on  the  heart  of  a 
frog  were  precisely  those  seen  when 
digitalin  is  used.  It  is  about  twenty 
times  weaker  than  the  adonidin  ob- 
tained from  the  European  Adonis 
vernalis. 

PHYSIOLOGICAL  ACTION.— 
Adonis  resembles  digitalis  in  its 
action  upon  the  heart  when  given  in 
therapeutic  doses.  It  increases  car- 
diac energy  and  raises  the  arterial 
tension.  The  increased  contractions 
eventually  diminish  and  a  period  of 
quiet  follows,  varying  in  duration 
with  the  dose  administered. 

The  prevailing  knowledge  of  the 
mode  of  action  of  adonis  is  based  on 
experiments  with  the  glucosid  adoni- 
din. The  results  have,  on  the  whole, 
been  contradictory.  While  Cervello 
and  Lesage  found  that  it  arrested  the 
heart  in  systole,  Huchard  and  Flare 
ascertained  repeatedly  that  this  organ 
was  arrested  in  diastole  and  Guirlet 
found  the  left  ventricle  in  systole  and 
the  other  cavities  in  diastole.  There 
has     been     greater     concordance     in 


432 


ADONIS    VERNALIS    (SAJOUS). 


respect  to  its  effects  on  the  blood- 
pressure,  all  observers  having  found 
that  there  was  first  a  rise,  then  a 
fall. 

While  the  primary  slowing  is  at- 
tributed to  the  inhibitory  action  of 
the  vagus,  since  its  section  prevented 
it,  Hare  found  that  the  diastolic 
arrest  was  not  due  to  this  nerve, 
since  it  occurred  after  the  latter  was 
divided,  while  galvanization  of  the 
nerve  later  on  also  failed  to  inhibit 
the  heart.  He  concludes,  therefore, 
that  adonidin  tends  secondarily  to 
paralyze  the  vagus — Kakowski,  in 
fact,  found  that  it  caused  dilatation 
of  the  coronaries  instead  of  contrac- 
tion of  these  arteries.  Hare's  experi- 
ments indicate  that  it  may  also  cause 
primary  stimulation  and  secondary 
paralysis  of  the  vasomotor  system. 

Adonis  has  been  credited  with 
diuretic  properties  by  Bubnow,  Alt- 
mann,  and  Michaelis,  though  their 
observations  have  failed  to  be  con- 
firmed by  certain  others.  Whatever 
diuretic  power  it  may  have  is  prob- 
ably the  result  of  activation  of  the 
renal  circulation   (Wood). 

[Viewed  from  my  standpoint,  the  evident 
confusion  which  attends  prevailing  knowl- 
edge concerning  the  action  of  adonidin  is 
due  to  the  fact  that  all  these  experiments, 
which  are  of  many  years  standing,  do  not 
take  into  account  facts  I  have  since  pointed 
out  (see  "Internal  Secretions,"  vol.  ii,  1907)  : 
(1)  That  the  inhibition  of  the  heart  is  due 
not  to  true  vagal  fibers,  but  to  vasomotor 
fibers  which  the  vagus  contains  and  trans- 
mits to  the  coronaries ;  (2)  that  the  caHber 
of  the  cardiac  arterioles  is  governed  by 
sympathetic  fibers,  and  (3)  that  the  secre- 
tion of  the  adrenals  takes  part  in  cardiac 
dynamism. 

If  now  adonidin  is  considered  as  a  stiiiiu- 
larit  of  the  adrenal  and  sympathetic  centers, 
instead  of  as  a  depressant  of  any  center,  the 
action  of  the  drug  becomes  plain :  by  excit- 
ing the  adrenal  center  it  increases  the  pro- 


duction of  adrenal  secretion,  and  thus  causes 
the  preliminary  rise  of  blood-pressure  while 
strengthening  cardiac  action.  A  larger  dose 
excites,  besides,  the  sympathetic  center,^  as 
this  center  governs  the  caliber  of  the  cardiac 
arterioles,  the  heart  muscle  receives  less 
blood  and  its  contractions  weaken  then 
cease,  with  failure  of  the  circulation  as  a 
normal  result — all  irrespective  of  the  vagus, 
v>'hich  does  not  contain  sympathetic  fibers. 
This  enables  us  to  explain,  also,  why  some 
experimenters  observed  that  the  heart  was 
arrested  in  systole,  while  others  found  it 
stopped  in  diastole.  These  results  are  con- 
tradictory simply  because  the  preparations 
differed  chemically.  Those  which  produced 
arrest  in  systole,  the  better  drugs,  excited 
more  actively  the  adrenals,  and  the  excess  of 
adrenal  secretion  caused  such  violent  con- 
tractions of  the  heart  muscle  that  the  organ 
finally  failed  to  dilate  (the  tetanic  or  cramped 
heart)  ;  on  the  other  hand,  the  poorer  drugs 
excited  more  actively  the  sympathetic  center, 
and,  the  cardiac  arterioles  being  unduly  con- 
stricted, the  heart  muscle  failed  to  receive 
enough  blood  to  sustain  its  contraction  and 
the  heart  remained  dilated,  i.e.,  in  diastole. 
S.] 

INCOMPATIBILITIES.  —  The 
glucosid  adonidin  in  solution  is  de- 
composed by  free  acids  or  alkalies. 
It  is  incompatible  with  tannic  acid, 
corrosive  sublimate,  and  silver  nitrate. 
The  physiological  incompatibilities  of 
adonis  include  aconite,  amyl  nitrite, 
muscarin,  veratrum  viride. 

CONTRAINDICATIONS.  — Ado- 
nis is  contraindicated  in  arterioscle- 
rosis, in  affections  attended  by  a 
high  vascular  tension  (as  in  the 
earlier  stages  of  interstitial  nephri- 
tis), and  in  hypertrophy  and  other 
disorders  of  the  heart  in  which  digi- 
talis, its  physiological  homologue,  is 
harmful. 

THERAPEUTICS.— Adonis  is  use- 
ful in  cases  of  valvular  heart  disease 
with  loss  of  compensation  and  in  which 
evidences  of  grave  circulatory  disorder, 
such  as  cardiac  asthma,  are  present.    It 


ADONIS    VERNALIS    (SAJOUS). 


433 


lias  been  specifically  recommended  in 
aortic  and  mitral  regurgitation.  The 
diuretic  powers  of  the  drui^"  cause  it 
to  be  of  value  in  cases  of  dropsy  and 
cardiac  degeneration.  It  is  also 
valuable  in  palpitation  dependent 
upon  irregular  inhibition.  As  it  does 
not  seem  to  possess  cumulative  tend- 
encies, it  may  be  administered  with 
more  freedom  than  digitalis.  Accord- 
ing to  Dujardin-Beaumetz,  however, 
large  doses  cause  gastric  disorders 
and  vomiting.  Borgiotti  found  adonis 
valuable  in  different  cardiac  disorders. 
One  dram  to  1  ounce  of  the  infusion 
daily  constitutes  an  excellent  cardiac 
tonic.  In  fatty  degeneration  of  the 
heart  it  increases  diuresis  and  regulates 
the  circulation. 

The  writer  found  the  drug  very 
useful  in  many  conditions  as  a  substi- 
tute for  digitalis,  though  its  action  is 
weaker;  but  it  has  the  advantage  over 
digitalis  of  being  free  from  disagree- 
able by-effects,  especially  effects  of  a 
cumulative  character.  It  is,  therefore, 
appropriate  for  long-continued  use, 
when,  for  some  reason,  the  adminis- 
tration of  digitalis  is  undesirable  or 
inadvisable.  A  satisfactory  form  of 
employment  is  a  1.5  to  2  per  cent,  in- 
fusion, which  may  be  prepared  by  the 
patient  himself,  and  the  dose  of  which 
is  a  tablespoonful  every  two  hours. 
Mutterer  (Therapie  d.  Gegenw.,  Oct., 
1904). 

Adonidin  is  credited  with  proper- 
ties superior  to  digitalis,  in  that  it 
acts  more  promptly  and  with  less 
tendency  to  cumulation.  As  Dujar- 
din-Beaumetz had  observed  in  the 
case  of  the  infusion  of  adonis,  how- 
ever, Lublinski  and  Durahd  have 
found  adonidin  to  produce  violent 
gastrointestinal  disorders  with  diar- 
rhea and  vomiting.  According  to 
Dujardin-Beaumetz,  the  dose  should 
never   exceed   %   grain    (0.02    Gm.) ; 


Iluchard  gives  yi2  grain  (0.005  Gm.) 
three  or  four  times  daily  in  adults. 

[The  therapeutic  value  of  adonis  or  adon- 
idin would  be  unquestionable  and  in  reality 
exceed  that  of  digitalis  were  we  able  to  ob- 
tain a  reliable  product.  This  is  especially 
true  in  view  of  the  fact  that  the  so-called 
''cumulative"  action  of  digitalis  is  due,  from 
my  viewpoint,  to  its  tendency  to  excite  the 
sympathetic  center,  while  a  good  preparation 
of  adonis  or  adonidin  does  not  possess  this 
defect.     S.] 

As  a  remedy  for  the  reduction  of 
obesity,  adonis  aestivalis  has  proved 
of  value.  Owing  to  the  fact  that  it 
does  not  possess  a  tendency  to  cumu- 
lation, it  may  be  continued  for  a  long 
time.  It  is  claimed  to  have  been 
eft'ective  in  relieving  the  heart  from 
an  excessive  covering  of  fatty  tissue. 
The  tincture  of  this  species  may  be 
given  in  doses  of  10  minims  (0.6  c.c.) 
three  times  daily. 

Case    in    which    the   patient   weighed 
342  pounds  and  suffered  severely  from 
dyspnea    when    the    administration    of 
adonis    was    begun.      After    taking    10 
drops  of  the  tincture  three  times  daily 
for   twelve    days    there    was   a    loss    in 
weight    of    17    pounds,    the    respiration 
had  become  easier,  and  there  was  gen- 
eral euphoria.    R.  Kessler  (Amer.  Med- 
ico-Surg.  Bull.,  Aug.  15,  1894). 
To     reduce     the     active     cerebral 
hyperemia  present  during  a  paroxysm 
of    epilepsy    adonis   has   been    recom- 
mended, owing  to  its  power  of  stimu- 
lating- the  vasoconstrictors.     It   may 
be  advantageously  combined  with  the 
bromides. 

[There  is  good  ground  for  the  belief  that 
adonis  is  a  valuable  remedy.  By  exciting 
the  adrenal  center  it  enhances  general  metab- 
olism, and  simultaneously  the  conversion  of 
the  spasmogenic  wastes  into  eliminable  prod- 
ucts, thus  preventing  the  fits.  It  was  used 
with  success  by  Bechterew  and  others.  S.] 
C.  E.  DE  M.  Sajous 

AND 

L.  T.  DE  M.  Sajous, 

Philadelphia. 
1—28 


434 


ADRENALS,    DISEASES    OF    (SAJOUS). 


ADRENALIN. 

TRACTS :  Adrenals, 


See  Animal  Ex- 


ADRENALS,  DISEASES  OF 
THE. —  Although  it  is  the  purpose  of 
this  Cyclopedia  to  present  the  prevail- 
ing or  current  views  upon  the  subjects 
treated,  the  writer  does  not  feel  that 
he  can  conscientiously  observe  this 
rule  in  the  present  instance.  Hav- 
ing probably  devoted  more  time  to  the 
study  of  the  ductless  glands  and  to  a 
comparative  analysis  of  the  work  done 
by  others  than  any  other  investigator  in 
this  comprehensive  field,  he  does  not 
hesitate  to  state  that  the  physiological 
role  authors  in  general  now  attribute  to 
the  adrenals,  though  correct  as  far  as  it 
goes,  represents  only  a  part  of  the  func- 
tions these  organs  actually  carry  on  in 
the  body.  To  be  more  explicit,  he  can- 
not admit  that  the  functions  of  the  ad- 
renals are,  as  stated  even  in  recently 
published  textbooks,  merely  to  raise  the 
blood-pressure  and  give  tone  to  the 
muscular  elements  of  the  heart  and 
blood-vessels ;  he  maintains  that,  besides 
these  well-known  properties,  the  adre- 
nals sustain  tissue  oxidation  and  metab- 
olism by  contributing  an  oxidizing  fer- 
ment to  the  hemoglobin,  and  that  they 
also  take  an  active  part  in  the  auto- 
protective  process  known  as  "immu- 
nity," the  active  agents  of  which,  not- 
withstanding the  great  amount  of  work 
devoted  to  the  subject,  have  never  been 
traced  to  their  original  source. 

[It  is  impossible  within  the  limits  of  an 
encyclopedic  article  to  review  at  length  the 
physiological  evidence  upon  which  these  four 
correlated  functions  are  based.  It  may  be 
recalled,  however,  that  the  action  of  the  ad- 
renal secretion  on  the  heart  and  blood-ves- 
sels was  first  pointed  out  by  Oliver  and 
Schafer  in  1894,  while  their  role  in  oxidation, 
general  immunity  and  fever  was  pointed  out 
by  myself  in  1903  in  my  work  on  "The  In- 
ternal    Secretions     and     the     Principles     of 


Medicine,"  the  fourth  edition  of  which  has 
recently  (1911)  appeared.  The  conclusions 
of  Oliver  and  Schafer  based  on  relatively 
simple  experiments  have  become  classic, 
while  mine,  which  required  experimental  in- 
vestigations from  many  directions,  physio- 
logical, biochemical,  clinical,  etc.,  by  a  cor- 
respondingly large  number  of  investigators, 
may  be  said  to  have  been  steadily  gaining 
ground. 

The  action  of  the  adrenal  secretion  on 
the  blood-pressure  and  cardiovascular  system 
discovered  by  Oliver  and  Schafer  being  fa- 
miliar to  every  one,  I  will  submit  only  a  sum- 
mary of  the  fundamental  features  which  sus- 
tain my  own  view  concerning  their  additional 
influence  upon  general  oxidation,  including 
metabolism,   immunity,   and    fever : — 

The  Adrenal  Secretion  in  Pulmonary 
and  Tissue  Oxidation. — The  prevailing  dif- 
fusion doctrine  as  to  the  absorption  of 
oxygen  from  the  pulmonary  air  and  the 
elimination  of  carbonic  acid,  having  been 
shown  by  Paul  Bert,  Miiller,  Setschenow  and 
Holmgren,  Bohr  and  other  authorities  to  be 
defective,  Bohr  concluded  in  1891  that  some 
internal  secretion  capable  of  taking  up  the 
oxygen  from  the  air  in  the  lungs  was  neces- 
sary to  explain  the  process.  A  comprehen- 
sive study  of  the  question  led  me  to  the 
conclusion  that  it  was  the  internal  secretion 
of  the  adrenals  which  carried  on  this  all- 
important  function.  The  following  are  but 
a  few  of  the  main  factors  in  support  of  this 
opinion : — 

1.  Ihe  marked  affinity  of  the  adrenal  secre- 
tion for  oxygen,  sustained  by  the  experi- 
mental observations  of  Vulpian,  Cybulski, 
Langlois,  Battelli,  Abel,  Takamine  and 
others^  including  the  writer. 

2.  The  presence  of  the  adrenal  secretion 
in  the  venous  blood  between  the  adrenals  and 
the  pulmonary  air  cells,  sustained  by  the 
experimental  observations  of  Gottschau, 
Manasse,  Aulde,  Stilling,  Pfaundler,  Cybul- 
ski and  Scymonowicz,  Biedl,  Langlois,  Dreyer, 
Salvioli  and  Pizzolini  and  personal  ana- 
tomical researches. 

3.  Tlie  marked  reducing  pozver  of  the 
blood  coursing  in  the  walls  of  the  air-cells, 
shown  by  the  experiments  of  Robin,  Verdeil, 
Garnier,  and  Miiller. 

4.  The  presence  in  the  hemoglobin,  of  a 
constituent  whose  physic o chemical  properties 
are  those  of  the  adrenal  secretion,  sustained 


ADRENALS,    DISEASES    OF    (SAJOUS). 


435 


by  the  observations,  first,  of  Vulpian,  Gaut- 
ier,  Moore,  Moore  and  Purinton,  and  Cybul- 
ski  as  to  the  properties  c  f  the  adrenal  prin- 
ciple ;  those  of  Battelli,  Dixon  and  Young  as 
to  the  presence  of  the  adrenal  principle  in 
the  blood;  of  Mulon  as  to  its  presence  in  the 
red  corpuscles;  of  Schmiedeberg,  Jaquet, 
Abelous  and  Biarnes,  and  Salkowski,  and  my 
own  as  to  the  presence  of  an  oxidizing  fer- 
ment in  the  blood;  of  Jolles  an  J  Poehl  as  to 
the  catalytic  and  oxidizing  properties  of  the 
adrenal  components  of  the  blood. 

5.  The  presence  of  the  hemoglobin  con- 
taming  the  adrenal  principle  in  all  parts  of 
the  body,  including  the  skin,  sustained  by  the 
presence  of  melanins  everywhere  and  their 
identity  as  hemoglobin  derivative  and  as  the 
adrenal  principle  based  on  the  investigations 
of  Leonard  "Hill,  Hirschfeld,  Chittenden  and 
Albro  as  to  melanin  being  an  hemoglobin 
derivative;  those  of  Boinet,  Miihlmann,  and 
myself  as  to  the  identity  of  melanin  (the 
bronze  pigment  of  Addison's  disease)  as  a 
product  of  the.  adrenals. 

6.  The  marked  influence  of  the  adrenal 
secretion  and  preparations  upon  the  tem- 
perature, general  oxidation,  and  metabolism, 
sustained  by  the  observations  of  Reichert, 
Morel,  Lepine,  Israel,  and  others,  including 
myself,  as  to  their  ability  to  cause  a  rise  of 
temperature ;  those  of  Brown-Sequard  and 
many  others,  as  to  the  steady  decline  of  tem- 
perature following  removal  of  the  adrenals, 
or  occlusion  of  the  adrenal  veins ;  the  hypo- 
thermia of  Addison's  disease;  the  observa- 
tions of  Byelaventy,  loteyko,  Dcssy  and 
Grandis,  and  others,  including  myself,  as  to 
the  increased  gaseous  interchanges  and  cellu- 
lar metabolism,  and  the  increase  in  the 
elimination  of  waste  products  caused  by  the 
adrenal  principle. 

The  Adrenal  Secretion  in  Immunity. — 
The  adrenal  secretion  in  this  connection  is, 
from  my  viewpoint,  but  one  of  the  antibodies 
which  carry  on  this  process,  being  what  has 
been  termed  by  Bordet  the  "fixative"  or 
"specific  immunizing  body"  and  by  Ehrlich 
"amboceptor."  Referring  to  "Internal  Se- 
cretions" for  details  which  cannot  be  em- 
bodied here,  upon  this  phase  of  the  question, 
I  will  limit  myself  to  the  direct  relationship 
of  the  adrenals  with  the  autoprotective 
functions : — 

The  adrenals  are  known  to  carry  on  anti- 
toxic functions.     Sustained  by  the   observa- 


tions of  Albanese  (1872),  which  showed  that 
removal  of  the  adrenals  reduced  the  resist- 
ance to  poisoning  by  neurine ;  those  of  Abel- 
ous and  Langlois  (1892-1898),  which  showed 
that  the  adrenals  neutralized  poisonous  sub- 
stances derived  from  muscular  activity  and 
bacteria!  products,  and  also  by  the  investiga- 
tions of  Mosse.  Additional  testimony  is 
afforded  by  the  marked  evidences  of  over- 
activity shown  by  the  adrenals  under  the 
influence  of  certain  waste  products  and  tox- 
ins, as  noted  by  Langlois  and  Charrin,  Petit, 
Stilling,  Auld,  Wybaux,  and  others,  and  also 
by  the  protection  afforded  by  adrenalin  in- 
jections against  strychnine  injections  ob- 
served by  Oppenheim,  Meltzer  and  Auer  and 
various  toxemias  and  infections  as  observed 
by  Hoddick,  Netter,  Marran  and  Dare, 
Moizard,  Kirchheimer,  and  many  other 
clinicians. 

The  relationship  between  the  adrenals  and 
general  oxidation,  shown  above,  also  estab- 
lishes a  connection  with  the  production  of 
fever,  which,  in  the  light  of  modern  work  is 
also  considered,  up  to  a  certain  limit,  as  a 
defensive  process.     C.  E.  de  M.  S.] 

To  disregard  functions  of  such  im- 
portance would  make  it  impossible  to 
-account  for  many  phenomena  aw^ak- 
ened  by  disorders  of  the  adrenals,  and 
correspondingly  limit  our  usefulness  in 
the  practical  field.  This  entails,  how- 
ever, the  necessity  of  granting  to  the 
adrenals  a  position  in  pathology  equal 
to  any  of  the  major  organs.  Indeed, 
the  functions  I  have  attributed  to  them, 
in  addition  to  those  with  which  they  are 
already  credited,  entitle  them  to  rank 
pathogenically  with  the  heart  and  blood- 
vessels in  so  far  as  the  general  vascular 
pressure  is  concerned,  and  the  lungs  in 
respect  to  respiration  and  tissue  oxida- 
tion. 

When,  moreover,  their  role  in  the 
autodefensive  or  immunizing  proc- 
esses of  the  body  is  also  taken  into  ac- 
count, their  importance  may  almost  be 
said  to  exceed  that  of  other  organs; 
since  they  thus  not  only  serve  to  sustain 
life  through  tissue  oxidation,  but  also  to 


436 


ADRENALS,    DISEASES    OF    (SAJOUS). 


protect .  life  through  their   role  in   im- 
munity. 

CLASSIFICATION.— Impairment 
of  these  functions  to  any  extent, 
through  factors  which  either  inhibit  or 
exaggerate  the  secretory  activity  of  the 
adrenals,  must  necessarily  awaken 
symptoms  which  indicate  the  functional 
disorders  present.  In  Addison's  disease 
(treated  by  Prof.  Langlois,  of  Paris, 
on  pp.  356-374  of  this  volume),  for 
example,  where  destruction  of  the  ad- 
renals or  of  their  secretory  nerves  by 
a  local  lesion  correspondingly  compro- 
mises their  functions,  we  have  as  main 
phenomena  not  only  the  vascular  hypo- 
tension and  cardiac  weakness  which  the 
well-known  action  of  the  adrenal  secre- 
tion on  the  blood-pressure  explains,  but 
also  the  low  temperature,  the  general 
coldness,  the  dyspnea  and  the  gradual 
emaciation  which  deficient  oxidation 
alone  accounts  for.  Now  if,  from  any 
cause,  the  functions  of  the  adrenals  are 
inhibited,  we  have  a  reproduction,  more 
or  less  marked  according  to  the  degree 
of  inhibition,  of  these  morbid  phenom- 
ena. They  form  the  symptom-complex 
of  the  condition  which  appears  to  me 
best  designated  by  the  term  "hypoad- 
renia." 

[This  term  was  selected  owing  to  its 
greater  exactness  and  brevity  than  "hypoad- 
renalism,"  and  owing  to  the  fact  that  the 
latter  suggests  the  presence  of  a  habit  such 
as  "alcoholism."  It  is  obviously  less  cum- 
bersome than  "insufhciency  of  the  adrenals" 
or  "adrenal  insufficiency,"  and  corresponds 
with  terms  in  current  use  such  as  "anemia," 
"asthenia,"  etc. 

In  1899  Sergent  and  Bernard  (Archives 
Generales  de  Medecine,  July)  were  the  first 
to  advance  the  view  that  adrenal  insufficiency 
was  a  syndrome  due  to  destruction  of  the 
adrenals,  but  standing  apart  from  Addison's 
disease,  which  they  ascribed  mainly  to  lesions 
of  the  abdominal  sympathetic.  My  own  re- 
searches ("Internal  Secretions,"  vol.  i,  1903. 
and  ii,  1907)   sustained  the  opinion  of  many 


other  observers,  however,  to  the  efifect  that 
the  elimination  of  Addison's  disease  was  not 
warranted,  and  that  this  disease  presented  the 
most  comprehensive  external  picture  of  grad- 
ual destruction  of  the  adrenals  or  of  the 
periadrenal  sympathetic  structures,  or  of 
these  structures  and  the  adrenals  jointly,  i.e., 
of  adrenal  insufficiency. 

Again,  Sergent  and  Bernard  ascribe  the 
syndrome  of  adrenal  insufficiency  as  a  whole 
to  a  general  intoxication  which  they  divide 
into  fulminant  (sudden  death),  acute  (rapid 
autointoxication),  and  subacute  (slow  auto- 
intoxication). From  my  viewpoint,  however, 
all  the  symptoms  excepting  the  convulsions 
are  due  to  the  inhibition  of  functions  which 
are  primarily  dependent  upon  the  adrenals : 
viz.,  general  oxygenation,  metabolism,  and 
nutrition.  The  only  intoxication  phenomena, 
the  convulsions  witnessed  in  these  cases,  I 
ascribe  to  the  accumulation  of  toxic  wastes 
(shown  by  Abelous  and  Langlois  to  be  an- 
tagonized by  the  adrenal  secretion)  which 
are  not  broken  down  with  sufficient  rapidity 
when  the  oxidation  processes  sustained  by 
the  adrenals  are  inhibited.     C.  E.  de  M.  S.] 

Of  the  various  forms  of  hypoadrenia 
is  one  which  is  practically  unrecognized, 
though  frequently  a  cause  of  death, 
mainly  among  children,  viz. : — 

TERMINAL  HYPOADRENIA. 

DEFINITION.— Terminal  hypoad- 
renia is  a  form  of  marked  asthenia 
which  occurs  late  in  the  course  of  an 
acute  febrile  disease  as  a  result  of  ex- 
hausting secretory  activity  of  the  ad- 
renals— acting  as  defensive  organs — in 
the  course  of  that  disease. 

[The  term  "terminal"  is  '  serted  here  be- 
cause it  is  important  to  differentiate  this 
form  of  hypoadrenia  from  that  which  occurs 
early  in  the  course  of  a  toxemia  and  known 
as  adrenal  hemorrhage,  treated  farther  on  in 
this  article.     C.  E.  de  M.  S.] 

PATHOGENESIS  AND  SYMP- 
TOMATOLOGY.—The  adrenals  be- 
ing admittedly  concerned  in  the  protec- 
tion of  the  organism  during  infections 
and  intoxications,  by  contributing  an 
excess   of    their    secretion   during  the 


ADRENALS,   DISEASES   OF    (SAJOUS). 


A%7 


febrile  stage  of  the  disease  (sometimes 
considerably  prolonged),  it  follows  that, 
after  this  stage  is  over,  the  adrenals 
should  lapse  into  a  condition  of  more 
or  less  temporary  insufficiency  through 
fatigue  or  exhaustion.  That  other  or- 
gans concerned  in  the  immunizing  pro- 
cess are  influenced  in  the  same  way 
must  doubtless  be  the  case,  but  the  fact 
remains  that  it  is  the  symptomatology 
■of  hypoadrenia  that  is  uppermost. 

In  lobar  pneumonia  and  broncho- 
pneumonia, for  instance,  resolution  may 
be  considerably  delayed  and  convales- 
cence likewise.  There  is,  late  in  the 
case,  extreme  adynamia  and  a  low 
blood-pressure,  the  temperature  is  below 
normal,  the  pulse  weak  and  more  or  less 
rapid,  and  death  from  heart-failure  is 
not  infrequent.  In  typhoid  fever,  hypo- 
adrenia is  commonly  observed.  The 
disease  assumes  what  is  now  known  as 
the  cardiac  type,  with,  late  in  the  case, 
extreme  prostration,  a  rapid,  weak  and 
sometimes  irregular  pulse,  hypothermia, 
and  a  marked  tendency  to  vertigo,  faint- 
ing, and  cardiac  failure. 

[Sicard  (Bull,  de  la  soc.  med.,  July  21, 
1904)  reported  the  case  of  a  young  woman 
in  whom  the  foregoing  symptoms  appeared 
on  the  ninth  day  of  a  bronchopneumonia. 
Extreme  muscular  weakness,  marked  hypo- 
thermia and  low  blood-pressure,  diarrhea, 
and  Sergent's  white  line,  which  denotes 
marked  adrenal  insufficiency,  were  present. 
On  the  fifteenth  day  the  blood-pressure  fell 
to  70  or  80  (7  or  8  per  cent,  potain)  and 
death  followed  three  days  later.  At  the 
autopsy  the  adrenals  were  found  hemor- 
rhagic. This  suggests  that  adrenal  lesions 
may  be  present  in  all  such  cases.  Yet, 
Ribadeau-Dumas  and  Bing  (Bull,  de  la  soc. 
anat.,  June  3,  1904)  have  witnessed  the 
sam.e  symptoms  in  cases  of  measles  which 
recovered,  while  Bossuet  (Gaz.  hebd.  des 
sci.  med.  de  Bordeaux,  Oct.  30,  1904)  refers 
to  8  cases  in  various  febrile  disorders  in 
which  typical  symptoms  of  adrenal  insuffi- 
ciency,   asthenia,    low    blood-pressure,     etc., 


developed  suddenly  and  disappeared  spon- 
taneously, aided  perhaps  by  adrenal  extract 
which  had  been  administered. 

As  stated  recently  by  Morichau-Beauchant 
(Le  progres  medical,  Oct.  9,  1909),  the  ad- 
renals seem  to  show  a  special  predilection 
for  certain  infections.  Diphtheria  easily 
leads  them  all  in  this  connection.  So  seri- 
ously do  these  organs  suffer  in  these  cases 
that  Sevestre  and  Marfan  have  termed  the 
type  "secondary  syndrome  of  malignant 
diphtheria."  Hutinel  ascribes  the  fulminat- 
ing cases  of  scarlatina  to  this  cause.  Tet- 
anus, erysipelas,  mumps,  certain  forms  of 
tonsillitis,  and  certain  streptococcic  infec- 
tions may  also  present  the  typical  syndrome 
of  hypoadrenia.  Goldzicher  (Wiener  klin. 
Woch.,  June  10,  1910)  was  led  by  his  re- 
searches to  conclude  that  in  the  various 
forms  of  septicemia  the  appearance  of  lower 
blood-pressure  was  to  be  ascribed  to  in- 
sufficiency of  the  adrenals.    C.  E.  de  M.  S.] 

When,  at  the  end  of  an  infectious 
disease,  the  case,  instead  of  proceeding 
to  convalescence,  remains  in  a  condition 
of  asthenia,  with  low  blood-pressure 
and  temperature,  there  is  good  ground 
for  the  conclusion  that  terminal  hypo- 
adrenia has  occurred.  Exhaustion  of 
the  adrenals  during  the  acute  process 
having  inhibited  the  secretory  activity 
of  these  organs,  the  above  symptoms 
result  from  inadequate  oxidation  of, 
and  metabolic  activity  in,  the  tissues. 
Sergent's  white  line,  brought  about  by 
gently  rubbing  a  narrow  streak  over  , 
any  part  of  the  abdomen  with  the  finger, 
may  be  obtained  in  the  majority  of  these 
cases.  After  a  short  period  the  area 
becomes  whitish  and  remains  so  a  short 

time. 

The  writer  announced  in  1903  that 
he  had  occasion  to  observe  a  condi- 
tion simulating  meningitis  in  a  young 
girl,  but  autopsy  revealed  complete 
cheesy,  degeneration  of  both  supra- 
renal capsules,  while  the  meninges 
were  intact.  A  white  line  appeared 
when  the  fingernail  was  drawn  across 
the  abdomen  of  the  patient,  and 
lasted    for    two    to    five    minutes.      He 


438 


ADRENALS,    DISEASES    OF    (SAJOUS). 


has  since  noted  this  white  line  in  a 
number  of  other  cases  in  which  the 
suprarenals  were  primarily  or  second- 
arily affected,  and  others  have  con- 
firmed his  observation.  The  writer 
has  never  observed  it  with  an  arterial 
pressure  above  13  (Potain — 130  mm. 
Hg).  It  disappears  on  administra- 
tion of  adrenalin,  and  is  evidently  due 
to  reflex  spasm  of  the  capillaries  dur- 
ing low  arterial  tension,  with  more 
or  less  dilatation  of  the  vessels.  The 
subject  was  discussed  at  the  meetings 
of  the  Paris  Societe  Med.  des  Hop.,  in 
February,  at  which  some  cases  of  the 
suprarenal  pseudomeningitis  were 
reported,  as  also  two  cases  of  insola- 
tion in  which  the  white  line,  or  a  par- 
tially red  line,  was  noticed.  In  both 
these  cases  lumbar  puncture,  with  re- 
moval of  20c.c.  of  fluid,  had  a  marked 
beneficial  effect,  especially  on  the 
headache.  The  fluid  was  compara- 
tively normal,  but  under  considerable 
tension.  Sergent  (Jour.  Amer.  Med. 
Assoc,  Apr.  20,  1907). 

The  writer  has  critically  examined 
the  significance  of  Sergent's  sign  in  79 
cases,  taking  the  blood-pressure  in  all 
of  them  with  Potain's  sphygmoma- 
nometer. The  white  line  was  present 
in  31  patients,  absent  in  41,  and  in- 
termittent in  7.  In  2  patients  with 
definite  lesions  of  the  suprarenals,  as 
proved  by  autopsy,  the  sign  was  ab- 
sent. In  the  31  cases  in  which  the 
sign  was  positive  the  blood-pressure 
was  low  in  8,  normal  in  7,  high  in  11, 
and  variable  in  S;  in  the  41  cases  in 
which  the  sign  was  negative  the 
blood-pressure  was  high  in  22,  nor- 
inal  in  8,  low  in  8,  and  variable  in  3. 
He  concludes  that  this  white  line  is 
not  a  sign  of  suprarenal  insufficiency 
and  is  not  dependent  on  low  blood- 
pressure.  L.  Bernard  (Bull,  et  mem. 
Soc.  Med.  d'Hop.,  Paris,  vol.  xxiv, 
p.  866,  1907). 

The  writers  found  the  white  line 
present  in  145  out  of  228  cases;  65  of 
these  had  hypotension  and  80  a  nor- 
mal or  hypertension.  The  83  cases 
which  did  not  give  the  test  included 
30  with  hypotension  and  53  with  nor- 
mal or  hypertension.     The  80  cases 


with  the  white  line  without  hypoten- 
sion and  30  with  hypotension  with- 
out the  white  line  make  a  total  of 
110,  or  one-half  of  the  228  cases 
tested,  which  do  not  conform  to  the 
rule.  They  conclude  that  the  white 
line  cannot,  therefore,  constitute  a 
sign  of  either  adrenal  insufficiency  or 
hypotension.  Lautier  and  Gregoire 
(Soc.  de  biol.,  vol.  Ixvii,  p.  690,  1910), 

The  patient  complains  of  chilliness; 
the  surface  is  pale,  owing  to  the  poverty 
of  the  blood  in  cellular  elements  and 
hemoglobin,  and  to  recession  of  the 
blood-mass  from  the  surface  to  the 
deeper  vascular  trunks.  The  vascular 
tension  being  low,  the  pulse  is  rapid  and 
the  heart-beat  weak.  Anorexia,  due  to 
deficient  metabolism  and  diminished  de- 
mand for  food,  nausea,  the  result  of  re- 
laxation of  the  gastric  muscular  coat, 
and  diarrhea,  due  to  a  similar  condition 
of  the  muscular  coat  of  the  already  pas- 
sively engorged  intestine,  and  more  or 
less  frequent  fainting  spells,  are  all  con- 
comitant symptoms  that  may  be  wit- 
nessed in  such  cases,  which  are  always 
greatly  exposed  to  relapse  or  to  sudden 
death  from  heart-failure. 

The  writer  published  with  Bernard 
a  description  of  this  syndrome  in 
1899.  He  now  reports  2  more  cases 
with  necropsy  which  corroborate  the 
existence  of  a  pseudomeningitis  orig- 
inating in  suprarenal  insufficiency. 
There  had  evidently  been  a  chronic 
affection  of  the  adrenals  in  each  case, 
clinically  latent,  until  fanned  into  a 
flame  which  proved  rapidly  fatal. 
One  patient  was  a  young  woman,  the 
other  a  man  of  32.  The  symptoms 
suggested  intoxication  from  the  sud- 
den suppression  of  the  suprarenal 
functions.  The  syndrome  may  simu- 
late, also,  acute  dyspepsia,  poisoning, 
peritonitis,  or  cholera.  The  combina- 
tion of  pains  in  the  epigastrium,  ano- 
rexia, vomiting,  extreme  prostration 
and  progressive  emaciation,  arterial 
hypotension  and  tachycardia  indi- 
cated the  suprarenal  origin,  but  other 


ADRENALS,    DISEASES    OF    (SAJOUS). 


439 


signs  such  as  instability  of  the  pu- 
pils, photophobia,  pain  on  pressure  of 
photophobia,  and  pain  on  pressure  of 
the  ej'eballs,  cutaneous  hyperesthe- 
sia, a  plaintive  cry  and  tardy  head- 
ache, indicated  meningitis,  notwith- 
standing the  absence  of  contractures, 
of  Kernig's  sign,  and  of  the  menin- 
gitis stripe,  with  the  retention  of  con- 
sciousness. The  necropsy  disclosed 
that  there  was  no  meningitis,  but 
merely  a  pseudomeningeal  reaction, 
a  suprarenal  encephalopathy.  Ser- 
gent  (Presse  med.,  ii,  No.  94;  Jour. 
Amer.  Med.  Assoc,  Jan.  2,  1904). 

The  author  has  observed  nine  cases 
of  acute  suprarenal  insufficiency  or 
variable  intensity,  ending  in  recovery. 
The  symptoms  develop  very  rapidly, 
and,  besides,  they  can  disappear  spon- 
taneously, at  the  same  time  with  the 
illness  which  they  accompany,  for  this 
acute  adrenal  insufficiency  is  due  to  an 
infection  or  an  intoxication.  The  writer 
has  always  noted  that  the  insufficiency 
occurs  in  the  course  of  a  toxic  or  infec- 
tious malady,  medical  or  surgical. 
The  longest  duration  of  this  acute 
suprarenal  insufficiency  that  the 
writer  has  observed  was  one  month 
and  a  half,  in  a  woman  who  was  suf- 
fering from  an  outbreak  of  syphilis. 
This  affection  has  yielded  to  the  em- 
ployment of  adrenal  extract.  The 
patients  treated  by  the  author  recov- 
ered from  the  suprarenal  insufficiency 
in  a  few  days.  In  eight  of  the  nine 
patients  the  cure  appears  to  be  defi- 
nite, for  the  symptoms,  which  disap- 
peared with  the  causal  illness,  have 
not  returned  after  an  interval  of  sev- 
eral months.  In  one  case  of  recur- 
rent bronchitis,  however,  with  every 
attack,  the  patient  became  asthenic 
and  the  skin  became  dark.  But  when 
the  attack  of  bronchitis  passed,  so  did 
the  insufficiency.  It  would  be  very 
difficult  to  say  to  what  lesion  of  the 
capsule  the  syndrome  corresponds. 
The  fact  that  this  insufficiency  is 
secondary  to  an  intoxication  or  in- 
fection is  the  characteristic  which 
gives  it  a  true  clinical  importance. 
G.  Bossuet  (Gaz.  hebd.  des  Sci.  Med. 
de  Bordeaux,  Oct.  30,  1904). 


Case  of  acute  insufficiency  of  the 
adrenals  in  an  apparently  healthy 
farmer  who  had  been  doing  some 
hard  work,  exposed  to  the  sun  for 
several  hours,  when  suddenly  he  col- 
lapsed with  intense  abdominal  pain 
and  headache,  with  great  prostration. 
On  the  presumptive  diagnosis  of  sun- 
stroke, he  was  treated  with  cold  to 
the  head  and  purgatives,  but  the 
symptoms  persisted,  soon  accompa- 
nied by  vomiting  and  hiccough;  the 
prostration  increased,  with  a  ten- 
dency to  stupor;  there  were  intense 
headache  and  delirium,  respiration 
was  superficial,  the  pupils  were  di- 
lated and  did  not  react  to  stimuli,  the 
heart-sounds  became  faint  and  death 
occurred  at  the  end  of  the  week.  The 
only  pathological  findings  at  autopsy 
were  atrophy  of  the  adrenals  from  a 
sclerotic  process  in  the  veins,  and 
compression  from  a  hematoma  from 
rupture  of  one  of  the  veins  in  the 
adipose  tissue  surrounding  the  left 
suprarenal  capsule.  The  writer  at- 
tributes the  acute  insufficiency  in  his 
case  to  excessive  exposure  to  the 
heat  of  the  sun.  Sotti  (Policlinico, 
Jan.  XV,  Med.  Sec.  No.  1,  1908). 

Symptoms  arising  in  the  course  of 
scarlatina  which  are  very  suggestive 
of  insufficiency  of  the  suprarenals. 
The  symptoms  are  asthenia,  depres- 
sion, failure  of  the  heart-power,  hypo- 
tension of  the  arteries,  tendency  to 
syncope,  abdominal  pains,  and  a 
brown  coloration  of  the  skin.  The 
use  of  small  doses  of  adrenalin  had 
a  remarkable  effect  in  the  cases  cited, 
the  patient  recovering  after  being  in 
an  apparently  desperate  condition. 
V.  Hutinel  (Le  bull,  med.;  Med. 
Record,  Sept.  18,  1909). 

Complications  of  various  kinds  may- 
occur.  The  immunizing  processes  be- 
ing greatly  weakened  through  the  defi- 
ciency of  adrenal  secretion,  one  of  its 
important  factors,  septic  infection,  ab- 
scesses, bone  lesions,  tuberculosis  of  a 
rapid  type,  and  other  infections  may 
more  or  less  rapidly  develop.  Disorders 
of    nutrition,  cholelithiasis,    and    occa- 


440 


ADRENALS,   DISEASES    OF    (SAJOUS). 


sionally  Addison's  disease  may  also 
appear.  In  acute  pulmonary  infections, 
pneumonia,  for  example,  organs  in  the 
neighborhood  of  the  focus  of  infection, 
the  pleura,  the  mediastinal  glands,  etc., 
being  inadequately  protected  by  the 
blood  or  its  phagocytic  cells,  become 
the  prey  of  specific  bacteria.  Briefly, 
the  body  is  rendered  vulnerable  to 
the  attacks  of  almost  any  pathogenic 
organism. 

PATHOLOGY.  — In  the  special 
type  in  question  no  adrenal  lesion  may 
be  discernible.  In  the  majority  of  in- 
stances, however,  the  organs  are  en- 
larged and  congested  and  may  show, 
here  and  there,  a  limited  hemorrhagic 
area.  Their  appearance  suggests  not 
only  the  functional  torpor  incident  upon 
functional  exhaustion,  but  the  presence 
of  a  passive  congestion  resulting  from 
loss  of  resiliency  of  their  sinusoidal  ves- 
sels, thus  impeding  the  circulation 
through  them.  Occasionally  they  are 
the  seat  of  suppuration,  a  complica- 
tion which  is  apt  to  be  observed  when 
the  causative  disease  is,  or  includes,  a 
streptococcic  infection,  pneumonia,  or 
meningitis.  , 

The  functional  disturbance  in  the 
adrenals  during  disease  estimated  by 
the  lesser  pressure-raising  power  of 
the  extract  in  various  animals.  It 
showed  that  the  adrenals  are  not 
materially  affected  by  various  patho- 
logical conditions,  starvation,  fever, 
etc.,  but  that  others,  such  as  uremia, 
phosphorus  poisoning,  diphtheria,  and 
various  infectious  processes,  appar- 
ently arrested  the  suprarenal  func- 
tions. The  extract  of  the  organs 
under  these  conditions  failed  to  dis- 
play the  normal  pressure-raising  prop- 
erty. F.  Luksch  (Wiener  klin.  Woch., 
Bd.  xvii,  Nu.  14,  1905). 

The  pathological  picture  of  the  more 
severe  form  of  adrenal  complications, 
i.e.j    intercurrent   hyperadrenia,    shows 


far  more  distinct  lesions  of  the  adrenal 
parenchyma.  Hence  the  typical  lethal 
phenomena  that  attend  many  of  these 
cases. 

Case  of  infarction  of  the  right  ad- 
renal which  would  appear  to  be  al- 
most unique,  as  no  mention  of  such 
a  condition  is  made  in  the  literature 
referred  to  by  RoUeston  in  his  lec- 
tures on  the  suprarenal  bodies.  Spe- 
cimen obtained  from  the  .body  of  a 
female  child,  aged  11  months,  who 
died  from  some  throat  trouble,  pos- 
sibly diphtheria.  On  opening  the  ab- 
dominal cavity  a  mass  of  the  size  of 
a  goose-egg,  and  resembling  a  hema- 
toma, was  found  in  the  right  renal 
region.  It  was  found  that  the  right 
adrenal  was  imbedded  in  this  mass; 
it  was  enlarged  and  firm,  but  very 
dark,  almost  black,  in  appearance,  as 
from  hemorrhage.  On  section  the 
lines  of  the  cortex  and  medulla  could 
be  seen  with  difficulty,  and  the  entire 
substance  of  the  gland  was  of  prac- 
tically the  same  consistency  and  dark 
color.  In  the  medullary  portion,  and 
corresponding  to  the  site  of  the  cen- 
tral vein,  was  a  large,  round,  whitish 
mass,  in  size  about  that  of  an  ordi- 
nary match,  which  had  all  the  ap- 
pearance of  a  thrombus.  This  could 
be  followed  throughout  the  length  of 
the  organ.  The  left  adrenal  showed 
some  hemorrhagic  spots,  both  in  the 
medulla  and  cortex,  but  otherwise 
was  healthy.  Woolley  (Jour,  of  Med. 
Research,  Mar.,  1902). 

Mott  and  Halliburton  have  found 
already  that  in  cases  of  death  from 
exhausting  diseases  the  adrenalin 
present  in  the  adrenals  was  dimin- 
ished or  absent.  The  writers  have 
extended  these  observations;  they 
have  examined  the  adrenals  in  the 
cases  of  50  adults  dying  from  various 
diseases.  The  glands  were  placed  in 
Cohn's  fluid  for  twenty-four  hours 
and  afterward  stained  with  Schar- 
lach  or  Sudan  III;  by  this  method 
the  chromafifinic  substance  and  the 
fat  were  demonstrated.  They  relied 
upon  this  demonstration  of  the 
amount    of   chromafifinic   granules    in 


ADRENALS,    DISEASES    OF    (SAJOUS). 


441 


the  cells  of  the  medulla,  and  did  not 
carry  out  the  physiological  test.  No 
appreciable  Ios3  of  the  substance  oc- 
curred during  twenty-four  hours  fol- 
lowing death,  as  told  by  control  ex- 
periments in  animals.  Adrenalin  was 
always  being  given  ofif,  especially  if 
the  splanchnics  were  stimulated.  The 
conclusions  drawn  from  their  work 
were  that  in  cases  of  acute  infection 
and  rapid  death  adrenalin  was  absent 
in  the  medulla;  this  applied  also  to 
cases  of  death  from  shock  and  from 
peritonitis  when,  in  short,  the  blood- 
pressure  was  low.  On  the  contrary, 
in  chronic  diseases,  such  as  phthisis, 
adrenalin  was  to  be  found  in  the  me- 
dulla. In  cases  of  high  blood-pressure 
adrenalin  was  present  and  distinctly 
increased.  F.  A.  Bainbridge  and  P. 
R.  Parkinson  (Brit.  Med.  Jour.,  Mar. 
11,  1907). 

In  25  experiments  on  guinea-pigs  and 
hedgehogs,  the  writer  found  that  in 
only  three  was  the  microscopic  condi- 
tion of  the  adrenals  approximately  nor- 
mal, while  in  the  remaining  22  very 
characteristic  changes  were  present, 
which  in  18  were  of  serious  degree,  con- 
sisting of  hemorrhages  and  necroses, 
alone  or  combined,  after  poisoning  with 
the  diphtheria  toxin.  Strubell  (Berl. 
klin.  Woch.,  March  21,  1910). 

TREATMENT.— In  these  particu- 
lar cases  the  use  of  adrenal  gland,  or 
of  pituitary  body,  which  acts  very  simi- 
larly but  with  less  violence  and  more 
lasting  effects,  sometimes  gives  surpris- 
ing results.  The  adrenal  product — 
which,  from  my  viewpoint,  is  also  the 
main  active  agent  in  the  neural  lobe  of 
the  pituitary,  as  shown  by  the  chromaf- 
fin test — supplies  precisely  what  the 
body  needs,  e.g.,  the  resumption  of  all 
oxidation  processes  (thus  restoring  gen- 
eral metabolism  and  nutrition),  and  a 
rise  of  blood-pressure,  which  causes  the 
blood  to  circulate  normally  in  all  organs, 
including  the  skin  and  the  adrenals 
themselves.  Indirect  effects  are  also 
obtained :   its   action   on  the  heart  in- 


creases the  contractile  power  of  this 
organ,  which  is  thus  rendered  capable 
of  projecting  the  blood  with  more  vigor 
through  the  lungs,  and  causes  oxygena- 
tion of  the  blood  to  become  more  per- 
fect. Recovery  is  also  materially  aided 
by  the  rise  of  blood-pressure  that  the 
adrenal  product  insures,  causing,  as  it 
does,  arterial  blood  to  be  driven  from 
the  splanchnic  area  toward  the  periph- 
eral organs,  including  the  lungs  and 
the  brain.  From  these  features  alone 
considerable  benefit  is  derived. 

If  we  recall,  moreover,  the  participa- 
tion of  the  adrenal  secretion  (which  the 
adrenal  preparation  administered  repre- 
sents) in  the  immunizing  process,  we 
have  the  added  factors  of  ridding  the 
blood  of  any  intermediate — and  there- 
fore toxic — wastes,  bacterial  toxins, 
etc.,  it  may  contain,  and  of  increasing 
phagocytic  activity,  thus  antagonizing 
efficiently  any  pathogenic  organism  that 
may  remain  to  compromise  the  issue. 

Thus  explained,  we  can  understand 
the  phrase,  "little  short  of  marvelous," 
applied  to  the  results  obtained  by  some 
clinicians.  We  can  also  understand  the 
marked  reduction  in  the  mortality  ob- 
tained by  Hoddick  (Zentralbl.  f.  Chir., 
Oct.  12,  1907)  in  cases  of  peritonitis 
following  appendicitis  accompanied  by 
uncontrollable  decline  of  the  blood- 
pressure,  cyanosis,  and  other  evidences 
of  collapse,  and  also  in  puerperal  toxe- 
mias, by  the  slow  intravenous  use  of  ad- 
renalin in  saline  solution.  Hoddick  as- 
cribes the  lowering  of  the  blood-press- 
ure to  paralysis  of  the  vasomotor  cen- 
ter; but  as  the  toxemia  is  the  cause  of 
this  condition,  an  agent  capable  of  coun- 
teracting both  cause  and  effect  is  neces- 
sary. This  is  met  by  the  adrenal  prin- 
ciple. Josue  (Soc.  Med.  des  Hopitaux, 
May  21,  1909),  in  typhoid  fever,  like- 
wise relieved  threatening  symptoms  by 


442 


ADRENALS,   DISEASES    OF    (SAJOUS). 


injecting  15  minims  (1  c.c.)  of  adrena- 
lin (1:1000  sol.)  in  1/2  to  1  pint  (250 
to  500  c.c.)  of  physiological  saline  solu- 
tion subcutanously.  The  influence  of 
-the  saline  solution  in  these  cases  must 
not  be  overlooked,  however.  Eight 
years  ago  I  urged  that  death  was  often 
due,  in  infectious  and  septic  diseases,  to 
the  fact  that  the  osmotic  properties  of 
the  blood  became  deficient,  and  advised 
the  use  of  saline  solution  from  the  onset 
of  th'2  disease.  The  reduction  in  the 
mortality  of  pneumonia  in  the  practice 
of  men  who  have  carried  out  this  sug- 
gestion has  demonstrated  its  value. 

[Several  clinicians  have  employed  much 
larger  doses  of  the  adrenal  active  prin- 
ciple with  profit.  Marran  and  Darre  (Jour, 
des  praticiens,  May  15,  1909)  found  it  of 
great  value  in  the  collapse  of  diphtheria 
with  marked  asthenia,  low  blood-pressure, 
and  subnormal  temperature.  Moizard  (Re- 
vue de  therap.,  Jan.  1,  1910)  recommends  ad- 
renal organotherapy  as  soon  as  asthenia  and 
low  blood-pressure  occur  in  any  infection. 
He  gives  daily  two  sheep's  fresh  adrenals, 
finely  divided  and  mixed  with  powdered 
sugar,  or  administers  the  active  principle,  10 
to  20  drops  daily  divided  in  five  or  six  doses. 
Kirchheimer  (Mijnch.  med.  Woch.,  Dec.  20, 
1910)  has  found  large  doses,  10  to  24  min- 
ims, safe  hypodermically  in  the  collapse  of 
pneumonia,  diphtheria,  and  scarlet  fever. 
Letulle  has  found  it  of  great  value  in  the 
latter  disease.  The  better  plan,  from  my 
viewpoint,  is  to  inject  it  with  saline  solution 
(at  108°  F.),  intravenously,  the  needle  of  the 
syringe  containing  the  adrenalin  being  in- 
serted into  the  rubber  tube  of  the  saline 
solution  apparatus.     C.  E.  deINI.  S.] 

Adrenal  organotherapy  is  useful 
both  for  differentiation  and  cure,  and 
the  writer  has  witnessed  the  entire  sub- 
sidence of  the  Addison  syndrome,  in- 
cluding the  disappearance  of  the  "white 
line"  under  the  influence  of  suprarenal 
medication.  Fresh  glands  from  young 
calves  may  be  used,  the  patient  ingest- 
ing from  1.5  to  2  Gm.  a  day  up  to  5 
Gm.,  or  the  dry  extract  can  be  taken. 
This  is  kept  up  for  ten  or  twelve  days. 


then  suspended  for  two  or  three,  and 
then  recommenced.  As  a  rule,  he  pre- 
fers the  extract  of  the  whole  gland,  but 
he  sometimes  uses  adrenalin.  He  has 
found  this  particularly  tiseful  in  infec- 
tious disease  when  he  suspected  supra- 
renal involvement.  Signs  of  cardio- 
vascular weakness  subside  under  the  in- 
fluence of  the  adrenalin,  and  the  white 
line  vanishes  and  reappears  parallel 
with  the  fluctuations  of  the  pulse,  which 
he  regards  as  substantial  proof  of  its 
pathognomonic  character.  The  usual 
dose  is  0.001  Gm.  a  day,  but  up  to  0.006 
may  be  given  fractioned  in  six  doses, 
and  this  may  be  kept  up  for  two 
months.  E.  Sergent  (Presse  med., 
July  10,  1909). 

Case  of  adrenal  insufficiency  due  to 
typhoid  fever  in  a  woman  of  46  years. 
The  symptoms :  low  blood-pressure, 
tachycardia,  a  persistent  feeling  of  cold- 
ness, marked  asthenia  and  lassitude, 
tendency  to  syncope,  vomiting,  stub- 
born constipation,  marked  anemia,  and 
emaciation,  lumbar  pains  radiating 
throughout  the  abdomen,  continued 
five  months.  Adrenal  organotherapy, 
of  all  the  remedies  tried,  was  alone  of 
value,  the  symptoms  recurring  as  soon 
as  it  was  stopped,  to  again  disappear 
when  the  use  of  adrenal  medication  was 
resumed.  After  five  days  the  patient 
was  able  to  rise ;  the  convalescence  pro- 
ceeded regularly  under  the  influence  of 
the  remedy.  Fortineau  (Gaz.  med.  de 
Nantes,  Feb.  28,  1910). 

[In  this  case,  the  adrenals  had  probably 
become  the  seat  of  organic  lesions  in  the 
course  of  the  febrile  process  which  had  re- 
duced their  functional  efficiency  to  a  marked 
degree,  the  adrenal  secretion  produced  being 
inadequate  to  raise  general  oxidation  and 
metabolism  to  the  needs  of  convalescence. 
Hence  the  almost  immediate  efifect  (noted 
the  next  day)  produced  by  addition  of  the 
adrenal  principle  to  the  blood  through  or- 
ganotherapy.    C.  E.  DE  M.  S.] 

Collapse  of  obscure  origin  sometimes 
occurs  in  the  course  of  infectious  dis- 
eases. This  accident,  which  not  infre- 
quently ends  fatally,  is  explainable  by 
lesions  of  the  adrenals.  The  success 
obtained  with  glandular  extracts  in  such 


ADRENALS,    DISEASES    OF    (SAJOUS). 


443 


cases  affords  evidence  in  favor  of  this 
view.  The  adrenals,  v^hen  active,  exert 
an  angiotonic  and  antitoxic  action,  and 
suppression  of  their  functions  results 
in  phenomena  akin  to  those  of  fatigue. 
In  infections  complicated  by  adrenal 
insufficiency  hemorrhages  into  these 
organs  have  often  been  noted.  If 
severe  and  bilateral,  such  hemorrhages 
result  in  death.  In  the  slowly  progress- 
ing forms  of  adrenal  failure,  treatment 
by  glandular  extracts  is  also  of  great 
value.  Such  treatment  is  indicated  as 
soon  as  asthenia  and  lowered  blood- 
pressure  appear.  The  author  recom- 
mends the  daily  administration  of  two 
capsules  of  fresh  suprarenal  substance 
from  sheep,  finely  divided  and  mixed 
with  powdered  sugar,  or,  better,  the  use 
of  adrenalin  solution  (1:1000)  or  of 
cachets  containing  glandular  extract. 
In  children  10  to  20  drops  of  the 
1 :1000  solution  may  be  given  daily, 
divided  into  five  or  six  doses.  Moizard 
(Revue  de  therap.,  Jan.  1,  1910). 

If  adrenal  insuflficiency  arises  during 
the  progress  of  diphtheria,  the  writer 
advises  combining  suprarenal  opother- 
apy with  serotherapy.  If  syphilis  is 
also  present,  suprarenal  opotherapy  may 
be  associated  with  mercurial  treatment. 
In  the  other  infectious  diseases,  where 
no  specific  medication  exists,  opotherapy 
should  be  begun  from  the  beginning  of 
the  symptoms  of  suprarenal  insuffi- 
ciency. Adrenalin  may  be  given  by  the 
mouth,  or,  if  the  hypodermic  method  is 
used,  1  c.c.  of  a  1:1000  solution  is 
added  to  SO  grams  of  normal  salt  solu- 
tion and  injected  into  the  subcutaneou-s 
tissue.  As  this  medication  is  inoffen- 
sive, it  can  be  continued  daily  until  the 
accidents  of  suprarenal  insufficiency 
have  disappeared.  Comby  (Archives 
de  med.  des  enfants,  Jan.,  1911). 

These  measures  are  only  indicated  in 
emergency  cases,  however.  In  the 
average  case  the  glandulae  suprarenales 
siccas  of  the  United  States  Pharmaco- 
peia, administered  by  the  mouth,  is  fully 
as  effective  if  a  good  preparation  is 
obtained  as  soon  as  asthenia  and  low 
blood-pressure  appear.    The  powder  in 


3-grain  (0.2  Gm.)  doses,  three  times 
daily,  in  capsules,  gradually  increased 
until  5  grains  are  given  at  each  dose, 
usually  suffices.  When  the  cardiac 
adynamia  disappears,  a  small  dose  of 
thyroid,  the  desiccated  gland,  y>  grain 
(0.03  Gm.)  ;  strychnine,  %o  grain 
(0.001  Gm.),  and  Blaud's  pill,  1  grain 
(0.06  Gm.),  added  to  each  capsule, 
greatly  hasten  convalescence.  The  iron 
and  the  adrenal  product  serve  jointly  to 
build  up  the  hemoglobin  molecule,  a 
slow  process  when  left  to  itself. 

For  our  knowledge  of  the  action  of 
the  use  of  pituitary  extracts  in  infectious 
diseases  we  are  mainly  indebted  to  L. 
Renon  and  Delille  (Bull,  de  therapeu- 
tique,  Feb.  8,  1907),  who  began  their 
use  in  1907.  In  a  recent  work  in  which 
the  clinical  observations  of  both  ob- 
servers are  recorded,  Delille  ("L'Hypo- 
physe  et  la  medication  hypophysaire," 
1909),  referring  to  grave  cases  of  ty- 
phoid fever,  states  that  they  showed 
"arterial  hypotension,  irregularity  of 
the  pulse  (especially  the  grave  forms), 
oliguria,  insomnia;  while  convalescents 
showed  asthenia,  hypotension,  or  at  least 
'effort  hypotension'  (Oddo  and  M. 
Achard),  paroxysmal  or  continuous  ta- 
chycardia"— all,  we  have  seen,  symptoms 
of  hypoadrenia  or  adrenal  insufficiency. 
They  found  1^  grains  of  pituitary  ex- 
tract (of  both  lobes)  at  noon  daily  ex- 
tremely efficient ;  it  counteracted  at  once 
the  depressed  arterial  tension,  produced 
diuresis,  counteracted  insomnia,  and 
greatly  improved  the  general  condition. 
Similar  effects  were  observed  in  diph- 
theria and  erysipelas.  The  results  in 
pneumonia  do  not  appear  to  me  to  war- 
rant the  use  of  any  adrenal  or  pituitary 
preparations  early  in  the  case,  the  first 
few  days  of  the  disease,  when  the 
blood-pressure  and  the  fever  are  high. 
They  should  be  used  only  when  a  low 


444 


ADRENALS,    DISEASES    OF    (SAJOUS). 


blood-pressure  and  other  symptoms  of 
hypoadrenia  are  present.  The  results 
reported  by  Delille  strengthen  this 
opinion.  In  advanced  tuberculosis  no 
beneficial  effect  was  observed. 

ACUTE  HYPERADRENIA  AND 
ADRENAL  HEMORRHAGE.— 
This  condition,  which  may  lead  to  fatal 
hypoadrenia  by  arresting  the  functions 
of  the  adrenals,  is  generally  known  un- 
der the  term  of  "adrenal  hemorrhage." 
The  association  with  hyperadrenia,  i.e., 
excessive  functional  activity  of  the  ad- 
renals, introduced  here,  is  important  in 
that  it  calls  attention  to  the  cause  of  the 
lethal  hemorrhage,  viz.,  abnormally  high 
temperature  and  blood-pressure. 

[Just  as  /zjz/'oadrenia  appears  to  me  to  re- 
place advantageously  "hypoadrenalism"  and 
"adrenal  insufficiency,"  so  does  "hyperadre- 
nia" seem  to  convey  more  exactly  excessive 
adrenal  activity  than  "hyperadrenalism," 
which  suggests  habitual  overactivity,  besides 
being  less  cumbersome  than  the  phase  "ex- 
cessive secretory  activity"  and  others  in  gen- 
eral use.     C.  E.  deM.  S.] 

This  disorder  is,  briefly,  the  result  of 
undue  activity  of  the  adrenals.  Hyper- 
emia of  these  organs  occurs  normally, 
i.e.,  physiologically  (owing  to  their  par- 
ticipation in  the  autodefensive  func- 
tions of  the  body),  in  the  course  of 
all  febrile  infections  or  intoxications. 
When  these  toxemias  are  severe  this 
adrenal  congestion  is  increased  in  pro- 
portion— sufficiently  so  in  some  in- 
stances to  cause  rupture  of  the  adrenal 
vascular  elements,  and  hemorrhage 
within  the  organs.  An  additional  cause 
of  congestion  in  the  latter  is  the  abnor- 
mal rise  of  blood-pressure  which  the 
unusual  production  of  adrenal  secretion 
entails ;  all  the  vessels  of  the  body  being 
unduly  contracted,  the  adrenal  capilla- 
ries, which  are  deprived  of  muscular 
elements,  are  overladen  with  blood  and 
prone,    therefore,   to    rupture.     These 


few  facts  are  necessary  to  elucidate  the 
definition  of  the  disorder. 

DEFINITION.— Acute  hyperadre- 
nia is  that  condition  of  the  adrenals 
characterized  by  intense  congestion  of 
their  vessels,  which  occurs  in  the  course 
of  severe  febrile  infections  and  certain 
intoxications,  and  manifested  by  a  high 
blood-pressure,  and  in  infections,  also, 
by  a  high  temperature.  When  this 
congestion  exceeds  the  resistance  of  the 
adrenal  vessels  adrenal  hemorrhage  oc- 
curs, causing  death  when  both  adrenals 
are  hemorrhagic,  in  a  large  proportion 
of  cases,  especially  infancy  and  child- 
hood. 

[The  limitation  "certain  intoxications"  is 
introduced,  because  active  congestion  of  the 
adrenals  is  produced  only  by  poisons  virhich 
cause  a  marked  rise  of  the  blood-pressure, 
strychnine  and  quinine,  for  example.  As 
shoum  m  "Internal  Secretions"  (vol.  i,  pages 
19  to  55,  4th  edition,  1911),  the  use  of  such 
remedies  in  the  course  of  infections  and  in- 
toxications may  do  harm  by  increasing  the 
congestion  of  the  adrenals  and  therefore  the 
chances  of  hemorrhage.     C.  E.  deM.  S.] 

SYMPTOMATOLOGY  AND 
PATHOGENESIS.— This  disorder  is 
relatively  common  in  children,  especially 
in  infants;  death  occurs,  from  adrenal 
hemorrhage,  without  premonitory  symp- 
toms, except,  perhaps,  a  hemorrhagic 
rash  or  purpura — denoting  excessive 
vascular  tension — over  the  body,  and  a 
high  temperature.  The  toxemia  here 
has  promptly  destroyed  the  adrenals. 
As  a  rule,  however,  more  or  less  marked 
phenomena,  besides  those  due  to  the  dis- 
ease from  which  the  child  may  be  suf- 
fering, and  varying  considerably  with 
each  case,  initiate  this  acute  phase  of 
the  process,  the  adrenals  being  on  the 
border-line  of  hemorrhage.  These  may 
include  vomiting  and  diarrhea,  melena, 
very  acute  abdominal  pain,  hemateme- 
sis,   icterus,    fever,   with   hyperpyrexia 


ADRENALS,    DISEASES    OF    (SAJOUS). 


445 


sometimes  immediately  before  the  ad- 
renal rupture.  W'lien  tlie  lieniDrrhage 
occurs  there  is  more  or  less  sudden  col- 
lapse, a  very  feeble  and  rapid  pulse, 
shallow  respiratitm  and,  perhaps,  some 
bronchial  rhonchi,  the  face  being  more 
or  less  dusky,  cyanosed,  or  even  livid, 
and  the  temperature  subnormal.  These 
pl^enomena  are  typical  of  adrenal  insuf- 
ficiency or  failure,  the  adrenal  secretion 
sustaining,  we  have  seen,  general  oxy- 
genation and  metabolism  and  cardio- 
vascular  contractility. 

Still  (Pathol.  Soc.  Reports,  1898), 
who  collected  the  cases  recorded  up 
to  1S9S,  divided  them  into  three 
groups: — 

1.  Those  in  which  death  occurred 
within  a  few  hours  or  days  of  hirth 
(never  later  than  the  sixth  day),  i.e., 
cases  of  congestion  or  hemorrhage  in 
the  suprarenals  in  the  newborn. 

2.  Those  in  which  death  occurred 
later,  and  the  suprarenal  lesion  was 
a  complication  of  some  disease,  usu- 
ally of  the  respiratory  tract. 

3.  Tliose  in  which,  after  an  acute 
illness  lasting  only  two  or  three  days, 
usually  with  a  purpuric  or  bulbous 
eruption,  death  occurs,  and  the  supra- 
renal lesion  appears  to  be  part  of  the 
fatal  disease. 

To  this  latter  group  belongs  a  case 
recorded  by  Voelcker  (Registrar's 
Reports,  Middlesex  Hospital,  1894), 
in  which  an  infant,  aged  2  years,  died 
with  acute  illness  and  purpura,  and 
was  found  to  have  hemorrhage  in 
both  suprarenal  capsules.  This  asso- 
ciation of  suprarenal  hemorrhage 
with  acute  illness  and  purpura  is  seen 
also  in  the  cases  recorded  by  Garrod 
and  Drysdale  and  Andrewes  (Pathol. 
Soc.  Reports,  1898),  and  in  a  recent 
case  at  the  Royal  Free  Hospital 
(Post-mortem  Reports,  1900).  An- 
drewes considers  that  we  have  clearly 
to  do  with  an  infective,  process,  and 
inasmuch  as  several  cases  have  oc- 
curred in  unvaccinated  children,  the 
question  of  variola  deserves  consider- 
ation.    Probably,  however,  the  asso- 


ciation IS  merely  an  accident  owing 
to  the  occurrence  of  death  in  infancy. 
Talbot's  cases  were  both  infants  with 
a  hi'story  of  sudden  onset  of  vomit- 
ing, abdominal  pain,  convulsions,  a 
temperature  of  100°  or  101°,  and 
nothing  discoverable  to  account  for 
the  symptoms;  purpura,  however, was 
not  present.  In  the  Royal  Free  Hos- 
pital cases  there  was  some  evidence 
of  acute  bronchial  inflammation. 
Still  considers  that  the  association 
with  a  respiratory  disease,  producing 
severe  dyspnea  and  cyanosis,  sug- 
gests an  asphyxial  origin  for  some  of 
the  cases  that  occur  in  later  infancy. 
Talbot  (St.  Bartholomew's  Hospital 
Report,  1900). 

Symptomatology  of  adrenal  hemor- 
rhage as  observed  in  80  cases:  (1)  In 
46  out  of  79  cases  there  were  no  appre- 
ciable signs.  (2)  In  5  cases  there  was 
a  voluminous  hematoma  or  abdominal 
tumor  that  could  he  perceived  by  pal- 
pation. The  diagnosis  was  made  in 
1  case  only  during  life.  (3)  There 
were  peritoneal  symptoms  in  6  cases, 
all  accompanied  by  tearing  of  the  cap- 
sule with  hemorrhage.  (4)  There  were 
symptoms  of  capsular  insufficiency  in  8 
cases.  (5)  In  15  cases  there  was  sud- 
den death,  or  death  after  three  days  at 
the  most,  sometimes  accompanied  by 
delirium,  convulsions,  contractures, 
coma,  hypothermia,  and  syncope.  In 
more  than  half  of  the  cases,  therefore, 
the  hemorrhages  remain  latent  and 
apparently  without  effect  upon  the 
organism.  F.  Arnaud  (Archives  gen. 
de  med.,  May,  1900). 

Series  of  four  cases  of  hemorrhage 
into  the  skin  and  suprarenal  capsules, 
the  interesting  features  of  which 
were  the  sudden  onset,  rapid  course 
and  fatal  termination.  Not  one  of 
the  patients  was  over  a  year  old. 
The  history  throws  absolutely  no 
light  on  the  causation  of  the  disease; 
neither  does  the  question  of  food  ap- 
pear to  bear  any  relation  to  it.  The 
presence  of  hemorrhage  in  the  skin 
and  suprarenal  capsules  would  seem 
to  make  it  more  probable  that  the 
disease  is  some  form  of  toxemia.  In 
two    cases    the    blood  from  the  un- 


446 


ADRENALS,    DISEASES    OF    (SAJOUS). 


opened  heart  was  examined  bacterio- 
logically  with  negative  results.  In  its 
extremely  rapid  and  fatal  termination 
the  disease  somewhat  resembled  the 
epidemic  diarrhea  .  and  vomiting  of 
infants.  The  general  condition  of  the 
patients  was  different.  They  did  not 
present  the  sunken  eyes  and  the  in- 
elastic skin  which  is  frequently  met 
with  in  the  epidemic  diarrhea,  and 
the  cyanosis  present  in  these  cases  is 
very  rarely,  if  ever,  seen  in  the  skin 
and  suprarenal  capsules;  the  fact  that 
Peyer's  patches  were  much  swollen 
is  interesting.  The  authors  believe 
that  these  symptoms  are  the  mani- 
festations of  a  special  disease,  and 
that  the  cause  of  this  disease  is  a 
blood  poisoning  of  some  form,  at 
present  unknown.  P.  S.  Blaker  and 
B.  E.  G.  Bailey  (Brit.  Med.  Jour., 
July  13,  1901). 

Three  cases  of  sudden  death  in  in- 
fants, due  to  hemorrhage  into  the 
suprarenal  capsules.  The  train  of 
symptoms  is  very  definite.  A  child, 
previously  well,  is  suddenly  seized 
with  acute  abdominal  pain  and  vom- 
iting, the  temperature  rises,  and  one 
of  the  exanthemata  is  suspected.  Xo 
characteristic  rash  appears,  however, 
though  sometimes  there  is  purpura. 
Convulsions  supervene,  the  patient 
becomes  moribund,  and  death  occurs 
in  a  few  hours.  If  the  condition  is 
in  infection  presumably,  it  is  a  spe- 
cial infection  of  unknown  origin.  Bac- 
teriological examination  has  proved 
negative  in  almost  every  case.  Lang- 
mead  (Lancet,  May  28,  1904). 

The  writer  was  in  attendance  at  birth 
of  a  full-term  male  child  born  after  a 
normal  labor.  The  umbilical  cord,  a 
thick  one,  was  tied  three  times  in  suc- 
cession on  account  of  bleeding  at  the 
seat  of  ligation.  This  was  finally 
checked  and  the  child  did  well  till  the 
ninth  day,  when  it  became  weak  and 
jaundiced.  In  a  few  days  more  red 
patches  appeared  on  the  chin  and  later 
on  various  bodily  areas.  Fever  and 
slight  convulsions  came  on,  and  the 
child  died  on  the  twentieth  day. 
Autopsy  revealed  a  dark,  slate-colored 
left    adrenal.     Opened    in    situ,    it    col- 


lapsed at  once  and  emptied  its  fluid 
contents  into  the  abdomen.  On  exam- 
ination it  appeared  to  be  converted  into 
a  blood-sac,  was  very  soft,  and  partly 
torn  in  removal.  There  were  no  signs 
of  inflammation  spreading  up  from  the 
umbilicus,  and  the  umbilical  cord  in- 
side the  abdomen  was  small,  pale,  and 
evidently  not  diseased.  The  brain  was 
not  examined. 

The  microscopic  report  was  as  fol- 
lows :  The  right  suprarenal  showed  no 
abnormal  appearances.  The  left  supra- 
renal was  much  broken  up,  but  there 
were  the  remains  of  hemorrhage  in  its 
medullary  substance,  both  in  the  form 
of  extravasated  corpuscles  and  as  gran- 
ules of  pigment.  B.  G.  Morrison  (Lan- 
cet, June  6,  1908). 

Case  of  a  man  35  years  old  who  suc- 
cumbed in  five  days  to  adrenal  hemor- 
rhage. The  disturbance  was  sudden  in 
its  onset,  with  symptoms  resembling 
those  of  intestinal  obstruction :  violent 
abdominal  pains,  which  morphine  was 
powerless  to  relieve,  continued  vomit- 
ing, and  absolute  retention  of  gas  and 
feces.  Laparotomy  was  performed  and 
showed  the  intestinal  tract,  including 
the  appendix,  to  be  entirely  normal. 
The  pain  was  in  no  way  modified,  by 
operation.  The  temperature  rose  to 
39°  C.  (102.2°  F.),  the  pulse  became 
extremely  feeble,  the  respiration  slow 
and  shallow,  and  death  took  place  on 
the  fourth  day  after  operation.  The 
autopsjr  showed  bilateral  lesions  of  the 
adrenajs,  without  other  dangers  of  any 
kind.  The  left  adrenal  gave  evidence 
of  a  recent  and  of  a  former  hemor- 
rhage (the  patient  had  experienced  a 
similar,  though  less  severe,  attack  a  few 
years  before). 

The  condition  of  the  abdomen,  slow- 
ing of  the  pulse,  with  temperature  re- 
maining normal,  should  draw  the  atten- 
tion from  the  intestinal  tract  to  the 
adrenals.  The  case  also  indicates  that 
this  syndrome  may  not  be  fatal,  and, 
if  not  fatal,  may  recur.  Brodnitz 
(Miinch.  med.  Woch.,  July  26,  1910). 

In  adults,  most  frequently  subjects 
between  20  and  30  years  of  age,  the  at- 
tack may  also  be  sudden,  or  preceded  by 


ADRENALS,    DISEASES    OF    (SAJOUS). 


AM 


a  period  of  great  lassitude  or  asthenia. 
In  most  instances,  however,  the  symp- 
toms are  such  as  to  suggest  acute  in- 
toxication or  infection,  with  very  severe 
pain,  either  in  the  epigastrium,  the  ab- 
domen or  below  the  costal  margin,  as 
the  pre-eminent  symptom.  Then  follow, 
in  rapid  succession,  incoercible  vomiting 
and,  perhaps,  diarrhea,  and  the  signs  of 
adrenal  hemorrhage :  great  weakness  of 
the  pulse  and  rapid  decline  of  the  blood- 
pressure,  hypothermia,  cold  sweats,  cold- 
ness of  the  extremities,  coma  and  death. 
This,  may,  however,  be  preceded  by  a 
typhoid-like  state,  delirium,  convulsions 
and  various  perversions  of  the  cuta- 
neous pigmentation,  varying  from  yel- 
low to  light-brown.  In  a  series  of  79 
cases  collected  by  Arnaud  (1900)  death 
occurred  within  a  period  ranging  from 
a  few  hours  to  three  days.  The  hemor- 
rhage may  be  due  to  the  rupture  of 
a  hemorrhagic  cyst  of  the  adrenals 
(treated  under  the  next  heading)  and  be 
preceded,  therefore,  by  the  symptoms 
peculiar  to  this  condition. 

The  types  of  acute  insufficiency  of 
the  suprarenals  are  classed  by  the 
writer  as  follows:  (1)  those  of  sud- 
den onset;  (2)  the  asthenic  type;  (3) 
the  nervous  type;  (4)  sudden  death 
where  nothing  but  a  destructive  le- 
sion is  found;  and  (5)  cases  which 
occur  in  hemorrhagic  diseases.  These 
types  often  overlap  each  other.  In 
the  asthenic  type  there  is  only  ex- 
treme asthenia,  followed  in  a  few 
days  by  death.  The  nervous  type  in- 
cludes those  showing  convulsions,  coma, 
delirium,  or  typhoid  states.  In  instances 
of  convulsions  the  convulsion  might 
well  be  the  cause  of  the  adrenal  le- 
sion. The  first  type  is  of  particular 
interest  because  of  its  striking  simi- 
larity to  acute  pancreatitis.  The  on- 
set is  sudden,  "with  epigastric  pain  and 
tenderness,  vomiting,  extreme  prostra- 
tion, feebleness  and  rapidity  of  pulse, 
coldness  of  extremities,  lumbar  ten- 
derness, and,  at  times,  diarrhea  and 


abdominal  distention,  followed  within 
a  few  days  by  death."  The  shock  is 
more  profound,  the  lumbar  tender- 
ness more  acute,  and  the  epigastric 
pain  and  vomiting  less  pronounced  in 
adrenalitis  than  is  usually  the  case 
in  acute   hemorrhagic   pancreatitis. 

Attention  should  be  paid  to  the  rela- 
tive frequency  of  the  condition  in  the 
purpuras  of  childhood  and  during  or 
shortly  after  the  acute  infections; 
and  due  consideration  must  be  paid 
to  the  apparent  insufficiency  and  in- 
flammations in  the  neighborhood  of 
the  suprarenals,  s  irf ace  burns,  chronic 
heart  or  pulmonary  disease,  and  any 
phenomenon  tending  to  a  great  in- 
crease in  internal  blood-pressure. 
Lavenson  (Archives  of  Intern.  Med., 
Aug.  15,  1908). 

ETIOLOGY.— That  we  are  deal- 
ing with  a  relatively  common  morbid 
process  is  shown  by  the  fact  that  Mattel, 
Rolleston  and  Le  Conte,  in  230  autop- 
sies in  the  newborn,  found  adrenal  hem- 
orrhage iri  over  100  instances,  or  45  per 
cent.,  while  the  proportion  in  adults  is 
about  1  per  cent.  To  explain  the  marked 
predilection  of  infants  to  this  disorder 
many  theories  have  been  advanced: 
Weakness  of  the  intra-adrenal  vessels, 
either  congenital  or  due  to  general  dis- 
orders, such  as  syphilis,  scorbutus,  or, 
again,  to  lesions  of  the  vascular  walls, 
such  as  fatty  degeneration,  aneurism, 
etc. ;  lack  of  firmness  of  the  medullary 
portion  of  the  organ,  the  usual  seat  of 
the  hemorrhage;  compression  by  the 
uterus  during  labor  of  the  inferior  vena 
cava,  thus  offering  resistance  to  the 
blood-streams  from  the  adrenals  which 
enter  this  great  venous  channel ;.  ligation 
or  prolapse  of  the  funis,  and  other  me- 
chanical factors  capable  of  causing  pass- 
ive congestion  of  all  organs,  including 
the  friable  and  extremely  vascular  ad- 
renals. 

Case    in    a    boy,    aged    18,    following 
operation    for    a    left    inguinal    hernia, 


448 


ADRENALS,    DISEASES    OF    (SAJOUS). 


though  before  the  patient  had  been  in 
perfect  health.  On  the  first  day,  Jan- 
uary 28th,  after  the  operation  the  pulse 
ranged  from  100  to  140;  it  was  normal 
on  the  second  day,  but  from  the  third 
day,  January  30th,  until  February  10th, 
it  ranged  from  100  to  140;  after  Feb- 
ruary 10th  it  was  normal  in  rate  but 
irregular  until  death,  February  15th. 
The  pulse  was  feeble  all  this  time. 
The  temperature  was  normal  until  the 
third  day  after  the  operation,  when  it 
gradually  rose  to  102°  F.,  where  it  re- 
mained for  two  days,  gradually  going 
down  to  normal  during  the  next  five 
days.  The  day  before  death  the  tem- 
perature was  subnormal.  The  urine  at 
no  time  showed  anything  abnormal. 
Immediately  after  the  operation  the 
patient  complained  of  pain  a  little  to 
the  left  of  the  median  line  under  the 
costal  margin  and  later  of  the  same 
kind  of  a  pain  under  the  right  costal 
margin.  This  pain  persisted  with  some 
tenderness  until  death.  On  the  fifth 
day  the  liver  reached  three  fingers  be- 
low the  costal  margin  and  was  then 
quite  tender,  but  on  the  ninth  day  it 
seemed  to  have  returned  to  its  normal 
size;  the  tenderness,  however,  persisted. 
Some  food  was  taken  every  day  and 
there  were  no  disturbances  of  the 
bowels,  but  the  patient  vomited  at 
different  times  after  the  fifth  day,  grad- 
ually losing  weight.  The  wound  healed 
by  primary  intention.  On  February  9th 
the  mind  seemed  somewhat  clouded  and 
gradually  became  more  so  until  death 
occurred,  February  ISth. 

Both  suprarenal  bodies  were  much 
larger  than  normal,  firmly  adherent  to 
the  surrounding  structures,  and  densely 
and  uniformly  infiltrated  with  blood  so 
that  their  appearance  was  like  that  of 
a  hemorrhagic  infarct.  In  places  there 
was  some  infiltration  of  blood  into  the 
tissues  about  the  suprarenal,  but  the 
main  hemorrhage  was  wholly  within 
this  organ.  On  the  cut  surface  it  was 
quite  smooth  and  red.  The  hemor- 
rhagic infiltration  was  most  intense  in 
the  medullary  part  and  appeared  to  be 
of  about  the  same  age  everywhere,  and 
microscopically  the  tissue  was  uniformly 
necrotic,  no  nuclei  being  demonstrable 


in  the  adrenal  cells;  some  of  the  vessels 
in  the  central  part  were  plugged  with 
clots  and  the  mouth  of  the  suprarenal 
vein  was  closed  by  a  firm,  adherent  and 
yellow  thrombus  which  projected  into 
the  vena  cava  as  a  small,  smooth,  oblong 
body  about  1  cm.  in  the  longest  dimen- 
sion. L.  Hektoen  (Jour.  Amer.  Med. 
Assoc,  June  12,  1909). 

Series  of  124  infants  in  whom  death 
occurred  within  eight  days  of  birth.  In 
8  of  these  cases  the  necropsy  revealed 
macroscopic  hemorrhages  in  one  or 
other  adrenals.  Two  of  these  8  cases 
were  delivered  spontaneously,  3  by  ver- 
sion, 2  were  foot  presentations,  and  1 
was  delivered  by  Cesarean  section. 
The  labors  in  most  of  the  cases  were 
difficult.  Three  had  asphyxia,  and  the 
Schultze  method  of  swinging  was  em- 
ployed. In  all  but  2  cases  the  infants 
died  within  eight  hours  of  birth.  The 
autopsy  in  these  cases  showed  usually 
anemia  and  icterus,  and  in  every  case 
hemorrhage  with  free  bleeding  in  one 
or  both  adrenals.  George  Magnus 
(Berl.  klin.  Woch.,  Bd.  xlviii,  S.  1119, 
1911). 

While  all  these  agencies  probably 
cause  hemorrhage  in  a  certain  propor- 
tion of  cases,  the  majority  are  due,  as 
stated  above,  to  some  form  of  intoxica- 
tion, either  toxins  or  endotoxins  of  in- 
fectious origin,  or  autogenous  poisons, 
such  as  toxic  waste  products  or  auto- 
toxins  of  intestinal  origin.  Some  ob- 
servers have  ascribed  the  morbid  pro- 
cess to  a  single  hypothetical  organism, 
but  it  has  been  clearly  shown  that  dif- 
ferent germs  could  produce  it,  including 
the  Staphylococcus  aureus  and  alhus 
(Riesman),  the  pneumococcus  (Hamill 
and  Dudgeon),  the  pneumobacillus  of 
triedlander  (Litzenberg  and  White), 
and  others.  In  adults  it  occurs  also,  as 
a  rule,  as  a  complication  of  various  dis- 
eases, some  of  which,  such  as  septicemia, 
erysipelas  and  tuberculosis,  are  clearly 
of  bacterial  origin.  Epilepsy,  on  the 
other  hand,  illustrates  the  class  of  cases 


ADRENALS,    DISEASES    OF    (SAJOUS). 


449 


in  which  adrenal  licmorrhagc  may  be 
caused  by  autogenous  poisons.  In  the 
adult,  as  shown  under  the  next  heading, 
several  of  these  morbid  processes  may 
give  rise  to  hemorrhagic  cysts,  which 
mav  eventually  rupture  into  the  abdom- 
inal cavity. 

[That  a  general  toxemia  is  an  active  factor 
in  adrenal  hemorrhage  has  been  demon- 
strated experimentally.  Roger  (Le  bull, 
med.,  Jan.  21,  1894)  found  that  inoculation 
of  the  guinea-pig  by  a  pure  culture  of  the 
pneumobacillus  of  Friedlander  is  followed 
by  abundant  hemorrhage  of  the  suprarenal 
capsules,  the  blood  bursting  through  the 
great  capsular  vein  and  causing  necrosis  of 
the  elements  by  mechanical  compression. 
These  hemorrhages  do  not  occur  in  the  rab- 
bit. Langlois  (Le  bull,  med.,  Feb.  7,  1894) 
saw  hemorrhages  produced  by  the  pyo- 
cyaneus  bacillus.  Pilliet  (Le  bull,  med.,  Feb. 
7,  1894)  has  also  observed  such  hemorrhage 
after  intoxication  by  essence  and  nitrate  of 
uranium.     C.  E.  de  M.  S.] 

The  adrenals  are  exceedingly  vas- 
cular, and  at  times  are  subject  to 
emporary  passive  engorgement.  An- 
other cause  of  hemorrhage  is  unques- 
tionably bacterial  invasion,  and  sev- 
eral hemorrhages  of  considerable  size 
have  been  reported  as  due  to  this 
cause.  The  hemorrhage  may  be  also 
due  to  toxemia  from  irritating  chem- 
ical poisons.  In  animals  who  have 
been  injected  for  experimental  pur- 
poses, with  sera  or  antitoxins,  as,  for 
example,  that  of  diphtheria,  severe 
congestions  and,  occasionally,  hemor- 
rhages have  occurred.  A.  J.  M'Cosh 
(Annals   of  Surg.,  June,   1907). 

Instance  in  an  epileptic  who  died 
during  an  attack  of  enteritis,  and  in 
whom  the  autopsy  revealed  recent 
extensive  hemorrhage  in  both  ad- 
renals. This  seems  to  be  a  rare  cause 
of  death  in  adults,  though  not  so 
uncommon  in  children.  The  reported 
case  is  one  of  Arnaud's  asthenic  type, 
probably  due  to  circulatory  failure 
from  sudden  removal  of  the  tonus, 
producing  secretion  of  the  supra- 
renals.  J.  F.  Munson  (Jour.  Amer. 
Med.  Assoc,  July  6,  1907). 


Case  of  adrenal  hemorrhage  and 
acute  edema  of  the  lungs  in  the  course 
of  convalescence  from  acute  nephritis 
due  to  erysipelas.  The  patient,  a 
woman  of  35  years,  died  suddenly  on 
the  fourth  day  of  the  nephritis,  which 
had  been  brought  on  by  exposure  to 
cold.  The  autopsy  showed,  besides 
the  evidences  of  pulmonary  edema 
and  intense  acute  nephritis,  great 
distention  of  the  adrenals  by  hemor- 
rhage into  them,  with  compleite  de- 
struction of  the  medullary  substance. 
Loederich  (Le  bull,  med.,  July  8, 
1908). 

From  an  extensive  experience  in 
autopsy  work  in  the  newly  born,  the 
writer  believes  that  hemorrhage  into 
the  suprarenals  is  very  common,  and 
that  the  evidence  is  sometimes  micro- 
scopic instead  of  macroscopic.  He 
has  found  some  degree  of  hemor- 
rhage in  infections  due  to  the  strep- 
tococcus, staphylococcus,  pneumococ- 
cus.  Bacillus  pyocyaneus,  the  colon 
bacillus  and  a  micrococcus  he  was 
unable  to  classify.  We  may  have  in- 
fections with  the  pneumococcus  with- 
out any  evidence  of  pneumonia.  S. 
M.  Hamill  (Jour.  Amer.  Med.  Assoc, 
Dec.  5,   1908). 

Hyperplasia  of  the  adrenal  is  an  al- 
most constant  lesion  in  arteriosclerosis 
associated  with  chronic  interstitial  ne- 
phritis and  left-sided  hypertrophy, 
and  it  occurs  with  almost  equal  fre- 
quency in  arteriosclerosis  with  chronic 
nephritis  of  the  parenchymatous  type ; 
it  is  also  a  frequent  lesion  of  arterio- 
sclerosis without  nephritis  and  of  ne- 
phritis without  arteriosclerosis.  Adre- 
nal hyperplasia  is,  consequently,  prob- 
ably the  result  of  some  factor  active  in 
a  period  of  life  in  which  these  affections 
are  most  frequent.  The  adrenal  lesion 
consists  of  increase  of  connective  tis- 
sue, round-cell  infiltration,  increase  in 
the  thickness  of  the  vascular  wall  a«d 
hyperplasia  of  the  adrenal  cells  proper. 
Pearce  (Jour,  of  Exper.  Med.,  Nov., 
1908).   ■ 

PATHOLOGY.  — An  important 
function  of  the  adrenals  is  to  destroy 
products  of  metabolism.    This  was  first 


1—29 


450 


ADRENALS,    DISEASES    OF    (SAJOUS). 


shown  by  Abelous  and  Langlois,  whose 
views  have  been  confirmed  by  many  ob- 
servers. Subsequently  this  function  was 
found  to  apply  to  bacterial  toxins.  The 
prevailing  view  as  to  the  pathogenesis 
of  adrenal  apoplexy  is  that,  as  a  result 
of  the  active  congestion  of  the  adrenals 
incident  upon  infection  and  excessive 
functional  activity  and  the  high  blood- 
pressure  resulting  therefrom,  or  passive 
congestion  due  to  factors  which  prevent 
the  free  passage  of  blood  out  of  the  or- 
gans, such  as  pressure  upon  the  adrenal 
veins,  the  inferior  vena  cava,  etc.,  the 
capillaries  become  engorged  and  yield, 
thus  causing  a  more  or  less  diffuse  inter- 
stitial hemorrhage.  In  some  instances 
the  entire  adrenal  parenchyma  is  de- 
stroyed, and  the  organ  is  more  or  less 
dilated  by  the  blood  accumulated  in  it, 
and  may  thus  form  a  brownish  or  red- 
dish-blue mass,  varying  in  size  from  that 
of  a  small  walnut  to  that  of  the  under- 
lying kidney.  In  other  cases  the  organ 
ruptures,  the  blood  flowing  into  the  peri- 
toneum or  the  abdominal  cavity.  Both 
adrenals  are  involved  in  the  morbid  pro- 
cess in  most  instances.  Other  organs, 
the  lungs,  the  pleura,  and  skin  in  par- 
ticular, may  also  be  the  seat  of  hemor- 
rhage, the  purpura  witnessed  in  a  large 
proportion  of  cases  being  naught  else 
than  a  punctiform  hemorrhage  into  the 
cutaneous  tissues,  due  to  excessive  vas- 
cular tension.  Death  may  be  due  to 
these  hemorrhages  or  to  the  annihilation 
of  the  functions  of  the  adrenals. 

Small  ecchymoses  into  the  adrenals 
occur  frequently  in  the  various  infec- 
tious diseases  and  are  to  be  considered 
toxic  in  origin.  Hemorrhagic  infarc- 
tion of  both  adrenals  often  leads  to 
peritonitis  and  collapse  and  may  result 
in  death.  It  may,  however,  occur  with- 
out any  of  these  sequences.  Large  hem- 
atomata  may  be  found  in  the  adrenals. 
Hemorrhage  into  these  glands  may  also 


occur  under  the  following  circum- 
stances :  traumatic  influences  (under 
this  class  is  found  the  form  seen  in 
the  newborn)  ;  hemorrhagic  diathesis ; 
thrombosis  of  the  suprarenal  veins, 
which  is  the  most  common  cause ;  and 
bacterial  capillary  embolism,  which  oc- 
cupies the  second  rank.  The  thrombi 
can  affect  the  trunk  or  the  tributaries 
of  the  suprarenal  veins;  they  can  occur 
in  both  or  only  in  the  right  organ;  they 
are  to  be  regarded  as  marantic  thrombi, 
occurring,  as  a  rule,  only  in  individuals 
suffering  from  some  form  of  chronic 
disease.  The  peculiar  anatomical  dis- 
position of  the  vessels  favors  their 
formation.  A  primary  suprarenal  dis- 
ease does  not  precede  these  cases. 
Under  the  cases  of  bacterial  capillary 
emboli  are  included  those  in  which 
neither  clinically  nor  anatomically  can 
septic  disease  be  observed.  Bleeding 
into  the  adrenals  may  lead  to  atrophy 
of  the  organ.  M.  Simmonds  (Vir- 
chow's  Archiv,  Nov.  3,  1902;  Med. 
News,  Dec.  27,  1902). 

Acute  hyperadrenia  and  adrenal  hem- 
orrhage in  the  infant  may  also  be  due 
to  toxemia.  While  the  fetus  is  in  utero 
its  waste  products  are  transferred  to  the 
maternal  blood  and  converted  therein 
into  eliminable  products.  When  its  birth 
occurs  it  is  left  to  its  own  resources,  and 
if  it  is  unable  fully  to  break  down  its 
waste  products  these  accumulate  in  its 
blood.  Its  waste  products — and  this  ap- 
plies as  well  to  certain  toxins,  including 
those  enumerated  above — excite  power- 
fully both  the  adrenal  system  and  the 
vasomotor  center  (hence  the  flushing 
following  a  copious  meal).  If  the  adre- 
nal system  can  thus  be  made  to  prevail, 
the  wastes  (or  toxins)  will  be  gradually 
destroyed,  and  the  vasomotor  center  will 
not  be  abnormally  excited.  If  it  is  not, 
the  wastes  accumulate,  and  the  vaso- 
motor center  being  powerfully  stimu- 
lated, the  vascular  tension  and  the  blood- 
pressure  become  intense ;  this  being  fur- 
ther enhanced  by  the  excess  of  adrenal 


ADRENALS,    DISEASES    OF    (SAJOUS). 


451 


secretion  produced,  the  pressure  be- 
comes such  that  the  adrenal  tissues,  al- 
ready overburdened  with  blood  as  a 
feature  of  their  overactivity,  yield — 
along  with  many  cutaneous  capillaries, 
as  witnessed  by  the  hemorrhagic  pur- 
pura. 

Case  of  a  child  who  had  been  brought 
to  the  Bellevue  Hospital  with  no  fur- 
ther history  than  that  it  had  been  blue 
since  birth.  It  had  died  very  suddenly 
a  few  minutes  after  entering.  At  the 
autopsy,  the  abdominal  cavity  was 
found  filled  with  blood,  and  the  intes- 
tines all  matted  together  by  very  firm 
adhesions.  On  the  superior  surface  of 
the  adrenals,  represented  by  a  more  or 
less  organized  blood-clot  of  a  consider- 
able size,  was  an  opening  two  inches  in 
diameter,  through  which  the  blood  had 
escaped  into  the  abdominal  cavity.  On 
examining  the  foramen  ovale  it  had 
been  found  nearly  closed.  The  ductus 
arteriosus  as  it  entered  the  aorta  pre- 
sented a  funnel-shaped  opening.  Hem- 
atomata  of  the  suprarenals  are  rarely 
as  large  as  the  one  presented.  This  is 
the  second  case  of  the  kind  that  the 
writer  has  met  with.  He  has  been  able 
to  find  only  one  or  two  instances  re- 
ported in  the  literature  in  which  rupture 
had  taken  place  into  the  peritoneal 
cavity.  One  observer  reported  26  cases 
in  which  there  have  been  small  hemor- 
rhages into  the  suprarenal  in  a  series  of 
over  100  autopsies  on  stillborn  infants. 
In  2  of  the  cases  the  hemorrhage  had 
started  in  the  cortex.  Charles  Norris 
(Med.  Record,  June  9,  1900). 

Examination  of  the  adrenals  in  16 
cases  of  diphtheria,  10  of  variola,  23  of 
lobar-  and  broncho-  pneumonia,  5  of 
typhoid  fever,  1  of  tetanus  and  4  of 
streptococcus  infection.  The  glandular 
cells  v/ere  profoundly  altered.  There 
was  also  hemorrhagic  extravasation  into 
the  stroma,  in  which  the  polynuclear 
neutrophilic  leucocytes  are  especially 
abundant.  True  abscess  formation,  oc- 
curs chiefly  in  the  prolonged  infections 
of  variola  and  typhoid  fever.  No  pecu- 
liar alterations  were  observed  as  the 
result    of    special    infections    and    the 


changes  in  general  were  common  to  all 
the  cases  examined.  A  pericapsular 
sclerosis,  cortical  and  central,  was  pres- 
ent in  most  cases.  This  chronic  lesion 
is  not  due  to  the  acute  process,  but  is 
to  be  regarded  as  the  result  of  previous 
repeated  or  continued  infections.  The 
writers  regard  the  adrenals  as  possess- 
ing an  important  function  in  the  re- 
sistance of  the  organism  to  infection. 
Oppenheim  and  Loeper  (Archives  de 
med.  exper.,  Sept.,  1901). 

Case  of  a  male  infant,  four  days  old, 
who  was  born  after  a  normal  labor. 
On  the  fourth  day  after  birth  the  infant 
ceased  to  pass  urine  and  after  total 
suppression  for  twenty-four  hours  it 
died.  At  the  autopsy  the  chief  interest 
centered  in  the  suprarenal  bodies ;  the 
left  one  was  replaced  by  a  tumor  the 
size  of  a  hen's  egg  and  the  right  one 
presented  a  tumor  as  large  as  a  cherry 
at  its  apex.  The  structure  of  both 
tumors  was  identical,  both  showing  a 
hypoplasia  of  the  fascicular  zone  fol- 
lowed by  marked  fatty  changes  and 
necrosis.  In  the  case  of  the  growth  in 
the  left  suprarenal  body,  liquefaction  of 
the  necrosed  central  portions  gave  rise 
to  a  cyst  which  was  filled  with  cell 
debris.  Both  growths  were  considered 
to  belong  to  the  group  of  adenoma. 
A.  S.  Warthin  (Archives  of  Pediatrics, 
Nov.,  1901). 

Results  obtained  by  inoculating  rab- 
bits and  guinea-pigs  with  cultures  of 
various  micro-organisms.  The  micro- 
organisms used  were  diplococci,  typhoid 
bacilli,  bacterivun  coli,  Staphylococcus 
aureus,  streptococci,  anthrax  bacilli, 
and  diphtheritic  bacilli.  In  the  ex- 
periments with  active  ctiltures  there 
was  always  great  hyperemia  of  the 
suprarenal  bodies  and  in  the  more 
active  cases  there  were  hemorrhages. 
E.  Frederic!  (Lo  Sperimentale,  Iviii, 
Fasc.  3,  1904). 

Common  pathological  changes  found 
in  the  suprarenals  are  hemorrhage, 
which  converts  the  medulla  of  the  organ 
into  a  pulpy  mass,  and  embolism  of  the 
suprarenal  artery,  whereby  the  entire 
organ  is  destroyed.  Occasionally,  one 
or  both  organs  will  be   converted  into 


452 


ADRENALS,    DISEASES    OF   '(SAJOUS). 


the  large  bluish  tumors,  whose  contents 
are  fluid  blood.  This  is  especially  com- 
mon in  the  newly  born,  and  many  be- 
lieve that  the  motions  necessary  for 
artificial  respiration  are  the  real  cause. 
In  a  number  of  cases  observed  by  the 
author,  however,  artificial  respiration 
was  not  resorted  to,  and  it  is  likely  that 
severe  labor,  particularly  if  the  child  is 
in  the  breech  position,  will  furnish  the 
necessary  trauma  to  rupture  the  friable 
suprarenal  tissue  and  thus  give  rise  to 
a  hematoma.  If  both  organs  are  af- 
fected the  symptoms  are  those  of  Addi- 
son's disease,  and  death  rapidly  sets  in. 
S.  Oberndorfer  (Wiener  klin.  therap. 
Woch.,  June  18,  1905). 

It  has  been  demonstrated  that  the  ad- 
renals have  the  function  of  neutralizing 
or  destroying  poisonous  products  result- 
ing from  muscular  work;  also  those  of 
uremic  poisoning,  and  of  poisons  in- 
troduced from  without.  The  author 
found  as  a  result  of  experiments  in 
rabbrts,  that  they  also  neutralize  the 
poisons  circulating  in  the  blood  as  a 
result  of  burns.  In  the  case  of  animals 
dying  within  a  few  hours  after  the 
burns,  he  noted  only  a  marked  dilata- 
tion of  the  vessels  of  the  suprarenal 
capsules ;  after  a  longer  period  a  marked 
hyperemia  resulted ;  after  three  to  five 
days  the  capsule  was  increased  in  vol- 
ume, and  there  was  hyperplasia  of  the 
glandular  epithelium,  testifying  to  an 
increased  activity  of  the  organ  and  a 
proliferation  of  the  cells.  Augusto 
Moschini  (Gaz.  Med.  Lombarda;  Med. 
Record,  March  25,  1905). 

Conclusions  based  on  a  study  of  119 
cases  including  2  personal  cases :  1. 
Hemorrhage  of  the  suprarenal  capsules 
is  more  common  than  hemorrhage  in 
the  other  viscera.  2.  This  is  due  pri- 
marily to  the  close  relation  of  the 
adrenals  to  the  vena  cava,  making 
congestion  easy,  and  to  the  peculiar 
anatomical  construction  which  favors 
hemorrhage.  3.  A  weakness  of  the  ves- 
sel walls,  either  normal  delicacy  or 
pathological  alteration  favors  the  rup- 
ture. 4.  The  place  of  election  of  the 
hemorrhage  is  visually  in  the  internal 
cortical  zone  because  of  its  vascularity 
and  the  anatomical  arrangement  of  the 


vessel.  5.  The  bleeding  always  follows 
active  or  passive  congestion.  6.  Pas- 
sive congestion  may  be  caused  by  diffi- 
cult labors,  obstetric  operations,  throm- 
bosis, or,  in  short,  anything  that  would 
favor  venous  stasis.  7.  Active  conges- 
tion is  induced  by  infection  or  any 
toxemia  which  incites  hyperemia  by  a 
superactivity  of  the  gland.  8.  The  find- 
ings of  the  pneumobacillus  of  Fried- 
lander  in  the  2  cases  personally  reported 
and  other  bacteria  in  5  additional  cases 
prove  beyond  question  that  infection 
is  a  cause  of  adrenal  hemorrhage.  9. 
Death  results  either  from  loss  of  blood 
or  an  interference  with  the  physio- 
logical function  of  the  gland.  J.  C. 
Litzenberg  and  S.  Marx  White  (Jour. 
Amer.  Med.  Assoc,  Dec.  5,  1908). 

TREATMENT.— The  literature  of 
the  subject  is  suggestively  silent  on  the 
prevention  and  treatment  of  this  condi- 
tion. The  foregoing  conception  of  its 
pathogenesis,  however,  opens  a  greater 
field  in  this  connection. 

As  to  prophylaxis,  it  must  be  borne  in 
mind  that  acute  hyperadrenia  is  present 
when  the  blood-pressure  and  the  febrile 
process  are  abnormally  high.  Antipy- 
retics are  worse  than  useless,  since  they 
further  increase  the  blood-pressure  and 
through  this  fact  the  danger  of  adrenal 
congestion,  which  may  lead  to  hemor- 
rhages. The  physiological  saline  solu- 
tion offers,  on  the  other  hand,  all  desir- 
able qualities.  It  does  not,  as  argued 
theoretically  by  some  authors,  increase 
the  vascular  tension,  even  if  injected 
intravenously,  as  shown  by  the  experi- 
ments of  Sollmann  (Archiv  f.  exper. 
Path.  u.  Pharm.,  Bd.  xlvi,  S.  i,  1901), 
Briggs  (Johns  Hopkins  Hosp.  Bull., 
Feb.,  1903),  and  others,  any  excess  of 
fluid  leaves  the  vessels  at  once.  By  re- 
ducing the  viscidity  of  the  blood,  saline 
solution  tends  to  relax  the  blood-ves- 
sels ;  by  increasing  its  osmotic  proper- 
ties it  facilitates  greatly  the  penetration 
of  the  plasma  into  the  lymphatic  chan- 


ADRENALS,    DISEASES    OF    (SAJOUS). 


453 


nels,  thus  further  rcchiciug  the  vascular 
tension.  The  hactericidal  and  antitoxic 
properties  of  the  blood  are  not  reduced 
in  the  least  by  this  procedure ;  there  is 
considerable  evidence  available  to  show, 
in  fact,  that  they  are  enhanced  (see  "In- 
ternal Secretions,"  4th  ed.,  vol.  ii,  p. 
1367,  1911).  Saline  solution,  therefore, 
should  be  used  intravenously  in  emerg- 
ency cases ;  subcutaneously  in  threaten- 
ing cases,  and  per  rectum  in  all  cases  in 
which  there  is  any  likelihood  Avhatever 
that  adrenal  hemorrhage  might  occur. 
If  employed  from  the  onset  of  all  infec- 
tions, as  I  suggested  in  1903,  the  blood- 
pressure  would  probably  never  be  raised 
sufficiently  to  endanger  the  adrenals. 

As  to  drugs,  we  have  several  at  our 
disposal  which  lower  the  blood-pressure. 
In  emergency  cases  nitrite  of  amyl  by 
inhalation,  with  nitroglycerin  (or,  in 
children,  the  sv^eet  spirit  of  niter)  to 
sustain  the  effect,  appears  indicated. 
Chloral  hydrate  has  been  used  advan- 
tageously by  J.  C.  Wilson  in  certain  ex- 
anthemata, to  subdue  the  cutaneous  dis- 
comfort and  as  a  sedative  ;  as  it  is  also  a 
vasomotor  depressor,  it  might  also  serve 
advantageously  in  all  but  infants  in 
whom  the  respiratory  mechanism  is  de- 
fective. Veratrum  viride  suggests  itself 
as  another  useful  agent  of  this  class. 
Of  all  measures,  however,  the  saline  so- 
lution is  much  to  be  preferred. 

When  the  hemorrhage  has  occurred 
the  lethal  phenomena  are  of  such  short 
duration  in  most  cases  as  to  have  sug- 
gested, we  have  seen,  the  term  "adrenal 
apoplexy."  In  a  fair  proportion  of 
cases,  however,  the  hemorrhage  causes 
sudden  hypoadrenia.  The  treatment  of 
this  condition  is  that  indicated  in  the 
emergency  cases  of  terminal  hypoadre- 
nia (see  page  441).  If  the  hemorrhage 
has  not  been  too  extensive  the  chances 
of  recovery  will  be  greatly  increased  by 


the  use  of  adrenal  or  pituitary  prep- 
arations, the  latter  owing  its  properties, 
in  my  opinion,  to  the  adrenal  chromaf- 
fin substance  the  pituitary  contains. 
These  agents  will  help  to  sustain  oxida- 
tion and  metabolism  while  the  adrenal 
lesion  is  undergoing  resolution. 

HEMORRHAGIC  PSEUDO- 
CYSTS OF  THE  ADRENALS.— 
In  most  instances  hemorrhagic  blood- 
cysts  are  the  results  of  acute  hyperad- 
renia  in  the  course  of  some  infection  or 
intoxication  in  which  the  adrenal  hem- 
orrhage has  been  limited  to  a  small  area, 
which  eventually  develops  into  such  a 
cyst. 

SYMPTOMS.— These  growths  may 
give  rise  to  no  symptom,  other,  perhaps, 
than  a  sensation  of  weight,  until  quite 
large,  when  pain  supervenes.  This  is  at 
first  indefinite,  though  most  marked  in 
the  region  of  the  tumor,  in  the  right  or 
left  loin,  or  in  the  upper  portion  of  the 
abdomen  and  loin.  The  neuralgia-like 
pain  becomes  increasingly  severe,  and 
radiates  in  various  directions,  especially 
toward  the  hip  and  thigh  of  the  corr.e- 
_sponding  side,  and  is  subject  to  exacer- 
bations, which  may  be  very  severe,  es- 
pecially after  meals.  Epigastric  pain 
and  vomiting — which  affords  relief — oc- 
cur in  some  cases,  especially  during 
these  exacerbations  of  suffering. 

The  tumor  may  manifest  itself  at  first 
merely  by  enlargement  of  the  abdomen. 
The  bulging  then  becomes  more  clearly 
defined  on  one  side  or  the  other  (this 
variety  of  growth  being  almost  invari- 
ably unilateral),  under  the  lower  ribs, 
which  may  be  pushed  outward  if  the 
growth  is  sufficiently  large,  or  below 
their  free  border,  i.e.,  between  them  and 
the  superior  spine  of  the  ilium.  If  the 
tumor,  which  grows  downward  and  for- 
ward, is  sufficiently  below  the  ribs  to  be 
palpated,  it  is  usually  found  globular,  or 


454 


ADRENALS,    DISEASES    OF    (SAJOUS). 


oval,  smooth  and  tense,  though  elastic, 
to  the  touch.  Fluctuation  may  also  be 
elicited.  In  some  cases  it  is  immovable 
under  palpation,  though  it  may,  at  first, 
follow  the  respiratory  movements.  Nor 
can  it  be  grasped  as  is  sometimes  possi- 
ble in  renal  tumors ;  if  small,  the  tumor 
is  movable,  either  upward  or  downward, 
but  this  mobility  gradually  decreases  as 
the  tumor  develops.  The  growth  is 
sometimes  sensitive  under  pressure. 

At  first,  several  years,  perhaps,  the 
patient  may  appear  normal  in  every 
other  respect,  be  well  nourished,  ruddy, 
etc.  With  comparative  suddenness,  how- 
ever, he  begins  to  fail,  losing  flesh  rap- 
idly, all  the  other  symptoms  mentioned, 
to  which  dyspnea  and  a  sense  of  con- 
striction about  the  chest  is  added,  be- 
coming more  severe.  If  the  cyst  does 
not  rupture,  polyuria,  hematuria,  and 
even  slight  bronzing  may  appear.  It  is 
probable,  however,  that  this  train  of 
phenomena  is  witnessed  only  in  a  very 
small  proportion  of  cases,  rupture  and 
hemorrhage  constituting  the  "adrenal 
hemorrhage"  in  adults  treated  under  the 
preceding  heading,  being  the  outcome  in 
practically  every  instance. 

Adrenal  hemorrhage  in  the  newborn 
is  probably  not  uncommon,  but  in  the 
great  majority  of  cases  there  are  no 
Symptoms  to  indicate  the  occurrence  of 
such  a  lesion,  and  the  hematoma  is 
quickly  absorbed.  It  is  equally  difficult 
to  understand  why  in  adults  these 
hemorrhages  should  occur.  The  deep 
situation  of  the  adrenal  bodies  would 
seem  to  be  sufficient  protection  from  in- 
jury, except  that  of  the  severest  char- 
acter, and  yet  in  a  certain  proportion 
of  these  cases  the  cause  has  aparently 
been  a  trauma.  A.  J.  M'Cosh  (Annals 
of  Surg.,  June,  1907). 

[This  abstract  indicates  the  drift  of  the 
prevailing  conception  of  the  pathogenesis  of 
these  growths.  While  local  lesions  are  as- 
cribed to  the  concomitant  disorder,  the  ad- 
renals, being  supposedly  affected  directly  by 


the  toxin  or  poison  that  may  be  present,  are 
thought  to  explain  some  cases,  others  require, 
it  is  believed,  some  form  of  traumatism. 
It  is  to  the  excessive  blood-pressure  pro- 
duced by  the  toxin  that  the  vascular  rup- 
tures to  which  the  hemorrhage  is  due  should 
be  ascribed.     C.  E.  de  M.  S.] 

DIAGNOSIS.— The  symptomatol- 
ogy of  adrenal  cyst,  apart  from  the  loca- 
tion of  the  tumor,  does  not  present,  as 
just  shown,  very  characteristic  features. 
The  location  of  the  pain  sometimes  sug- 
gests intercostal  neuralgia;  but  inas- 
much as  pain  occurs  only  when  the 
growth  is  large,  percussion  and  palpa- 
tion will  reveal  the  presence  of  a  tumor. 
In  neuralgia  the  pain  is  also  apt  to  be 
localized,  thus  distinguishing  it  from  the 
radiating  pain  of  adrenal  cyst.  The  sud- 
den onset  of  severe  pain  may  be  taken 
for  acute  pancreatitis.  The  location  of 
pain  and  tenderness  in  the  upper  left  ab- 
dominal quadrant,  the  subnormal  tem- 
perature and  the  early  lethal  trend — 
death  occurring  sometimes  within  three 
days — clearly  point  to  the  latter  dis- 
ease. Pancreatic  cyst  is  also  differen- 
tiated by  its  location  and  its  association 
with  glycosuria,  stearrhea,  and  imper- 
fect digestion  of  fats  and  albuminoids. 
Hydatid  cyst  of  the  liver,  another  source 
of  confusion,  is  attended  by  the  presence 
of  biliary  pigments  in  the  urine,  the  ap- 
pearance of  cysts  in  the  stools  and  vom- 
ited matter,  and  with  obstruction  phe- 
nomena. Cancer  of  the  spleen  may  be 
recognized  by  the  more  nocftilar  outline 
of  the  growth  and  the  cachectic  phe- 
nomena. 

Hydatid  cyst  of  the  spleen  is 
usually  associated  with  hydatid  cysts 
elsewhere,  and  may  be  accompanied  by 
the  presence  of  booklets  in  the  excre- 
tions. Puncture  of  the  growth  should 
be  carefully  avoided  when  there  is  any 
suspicion  whatever  that  an  adrenal 
blood-cyst  is  present.     Renal  cysts  are 


ADRENALS,    DISEASES    OF    (SAJOUS). 


455 


more   easily   palpatetl   bimanually,   and 
arc  usually  freely  movable. 

Only  nine  cases  of  large  serous 
cysts  of  the  adrenals  are  on  record. 
Case  personally  observed',  in  which  a 
serous  cyst,  probably  of  lymphatic 
origin,  had  developed  in  the  left  su- 
prarenal capsule.  As  the  other  supra- 
renal was  sound,  there  were  no  signs 
of  Addison's  disease.  Tumors  of  this 
kind  have  a  very  slow  development, 
but  gradually  push  up  the  diaphragm, 
distending  the  lower  part  of  the  tho- 
racic cavity  and  finally  protruding  in 
front  below  the  costal  arch.  The 
neighboring  organs  are  displaced 
to  a  remarkable  extent,  and  com- 
pression of  the  abdominal  sympa- 
thetic is  liable  to  cause  severe  pains. 
Terrier  and  Lecene  (Revue  de  Chir., 
vol.  xxvi,  No.  9,  1906). 

ETIOLOGY.— Adrenal  blood-cyst 
has  been  ascribed  to  many  morbid  condi- 
tions. Acute  intoxications,  especially 
diphtheria,  typhoid  fever,  burns,  osteo- 
myelitis, hepatic  abscess  and  tuberculo- 
sis, have  been  regarded  as  initial  factors 
of  these  growths,  a  small  cyst  formed 
during  the  active  stages  of  these  dis- 
eases, or,  as  a  complication  thereof, 
gradually  increasing  in  size  until  the 
foregoing  phenomena  or  adrenal  hem- 
orrhage occur.  In  the  light  of  the  data 
submitted  in  the  foregoing  pages,  they 
are  merely  after-effects  or  complica- 
tions, in  other  words,  of  the  damage 
done  to  the  adrenals  during  an  acute 
febrile  toxemia. 

Atheroma  of  the  adrenal  arteries  is 
also  regarded,  and  doubtless  justly,  as  a 
source  of  initial  lesions,  but  it  is  prob- 
able that  cerebral  lesions  of  the  same 
kind  and  apoplexy,  which  have  been 
considered  by  some  authors  as  etiolog- 
ical factors,  are  merely  concomitant 
lesions  due  to  general  arteriosclerosis. 
Thrombosis  of  the  adrenal  vein  by 
blocking  the  efferent  circulation  has  also 


been  incriminated,  while  traumatism  is 
known  to  have  started  the  morbid  proc- 
ess in  at  least  two  instances. 

PATHOLOGY.— While  older  in- 
vestigators, including  Klebs,  Virchow 
and  Heuschen,  considered  these  growths 
as  retention  cysts,  similar  to  those 
formed  in  the  thyroid,  and  thus  termed 
them  "struma  adrenalis,"  the  prevail- 
ing view  at  the  present  time  is  that  a 
small  hematoma  or  an  acute  congestive 
process — though  erroneously,  in  my 
opinion,  ascribed  to  local  intoxication — 
initiates  the  growth.  As  the  latter  in- 
creases in  size  the  adrenal  structure  is 
gradually  destroyed  and  the  content  is 
no  longer — unless  a  recent  hemorrhage 
has  occurred — merely  blood,  but  a  more 
or  less  fluid  magma  of  detritus,  broken- 
down  blood-  and  tissue-  cells,  flakes 
or  fibrin,  cholesterin  crystals,  etc., 
which  may  be  dirty  yellow,  greenish  or 
brownish  *in  color.  Microscopically,  the 
walls  of  the  cyst,  which  vary  from  Y^q 
to  %  inch  in  thickness,  are  composed  of 
fibrin  tissue;  the  inner  aspect  shows 
shreds  or  remnants  of  the  adrenal 
cortex. 

Certain  thickened  portions  of  the 
capsule  and  what  semiorganized  clots 
the  cyst  may  contain  may  be  found  to 
include  small  cysts,  chalky  deposits. 
These  growths  sometimes  become  very 
large — as  large  as  an  adult  head  in  a 
case  of  Chiari's — and  contain  several' 
pints  of  blood  or  liquefied  blood  and  tis- 
sue elements. 

PROGNOSIS.— The  fact  that  this 
growth  is  practically  always  unilateral, 
and  that  the  loss  of  one  adrenal  does 
not  compromise  life,  as  does  removal  of 
both  organs,  make  it  possible  to  remove 
the  growth  with  safety.  The  frequent 
instances  of  severe  collapse  and  shock 
that  have  followed  these  operations  sug- 
gest that  the  operative  prognosis  can- 


456 


ADRENALS,    DISEASES    OF    (SAJOUS). 


not  but  be  improved  by  resorting  to 
those  surgical  procedures  which  will  en- 
tail the  least  possible  handling  of  the 
intraperitoneal  organs  and  of  the  sym- 
pathetic ganglia,  all  of  which  are  well 
known  to  produce  shock  readily  by  re- 
flex action. 

TREATMENT.— The  treatment  is, 
of  course,  entirely  surgical.  The  cyst 
may  be  removed  through  either  an  ab- 
dominal or  lumbar  incision.  In  accord 
with  M'Cosh's  advice,  which  a  review 
of  the  operative  results  recorded  fully 
sustains,  preference  should  be  given  to 
the  lumbar  incision.  The  approach  is 
more  -direct;  it  avoids  the  handling  of 
the  intraperitoneal  organs,  which  must 
necessarily  take  place  if  the  tumor  be 
reached  through  the  abdominal  incision, 
and  it  affords  the  most  direct  route  for 
drainage.  In  the  average  case,  an  ob- 
lique incision  from  behind  downward 
and  forward  below  the  last  rib,  which 
has  been  found  most  convenient  for  ex- 
tirpation of  the  kidney  and  ureter,  is  as 
applicable  here.  If  much  space  is  needed, 
it  is  safer  to  remove  the  last  rib  than,  as 
some  European  surgeons  have  advised, 
to  resort  to  the  abdominal  incision, 
which,  as  previously  stated,  entails  con- 
siderable shock.  The  tumor  is  some- 
times found  so  firmly  adherent  to  the 
kidney  that  removal  of  this  organ  be- 
comes necessary. 

Personal  case  in  which  the  growth 
was  successfully  removed  through  a 
lumbar  incision.  The  main  dangers  of 
the  operation  are  hemorrhage  from  the 
pancreas  or  the  larger  veins,  and  injury 
to  the  descending  colon  or  to  the  sym- 
pathetic plexus.  These  cysts  are  usually 
very  adherent  and  considerable  time  is 
consumed,  and  blood  lost  in  enucleation 
of  the  sac.  The  adhesions  toward  the 
vertebral  column  and  abdominal  aorta 
are  especially  troublesome,  and  in  some 
of  the  cases  subjected  to  operation  have 
prevented  complete  removal  of  the  cyst. 


Severe  collapse  has  followed  many  of 
the  operations.  This  may  be  due  to 
blood  lost,  time  of  exposure,  shock  due 
to  peeling  the  tumor  from  the  dia- 
phragm or  sympathetic  nerves.  A.  J. 
M'Cosh  (Annals  of  Surg.,  June,  1907). 
In  the  case  of  large  serous  cysts 
complete  extirpation  should  be  prac- 
tised if  possible;  but  if  the  sac  can- 
not be  readily  and  gently  detached 
from  the  surrounding  parts,  the  sur- 
geon should  rest  content  with  partial 
resection  of  the  wall  of  the  cyst,  and 
with  the  method  of  marsupialization, 
in  which  the  margins  of  the  sac  are 
attached  to  the  external  wound  and 
the  cavity  is  packed  and  drained.  The 
results  of  the  operative  treatment  of 
large  suprarenal  cyst  have  not,  up  to 
the  present  time,  been  satisfactory. 
Five  cases  only  have  been  thus  dealt 
with,  of  which  three  were  fatal.  Ter- 
rier and  Lecene  (Revue  de  Chir.,  vol. 
xxvi,  No.  9,  1906). 

FUNCTIONAL  HYPOADRE- 
NIA. 

DEFINITION.— Functional  hypo- 
adrenia  is  the  symptom  complex  of  de- 
ficient activity  of  the  adrenals,  due  to 
inadequate  development,  exhaustion  by 
fatigue,  senile  degeneration,  or  any  other 
factor  which,  without  provoking  organic 
lesions  in  the  organs  or  their  nerve- 
paths,  is  capable  of  reducing  their  secre- 
tory activity.  Asthenia,  sensitiveness  to 
cold,  and  cold  extremities,  hypotension, 
weak  cardiac  action  and  pulse,  anorexia, 
anemia,  slow  metabolism,  constipation, 
and  psychasthenia  are  the  main  symp- 
toms of  this  condition. 

SYMPTOMATOLOGY  AND 
PATHOGENESIS.— The  process  of 
development  in  the  child  and  the  influ- 
ence of  senility  on  the  adrenals  make  it 
necessary  to  discriminate  between  the 
main  stages  of  life,  infancy,  childhood, 
adult  and  old  age,  in  describing  this  con- 
dition. 

Infancy. — Although  the  adrenals 
are  relatively  large  in  the  infant  (one- 


ADRENALS,    DISEASES    OF    (SAJOUS). 


457 


third  the  size  of  the  kidney  at  birth), 
their  functions  are  Hmited  to  the  carry- 
ing on  of  the  vital  process,  at  least  dur- 
ing the  first  year  of  life,  the  mother's 
milk  supplying  the  antitoxic  products 
capable  of  protecting  it  against  the  de- 
structive action  of  poisons  of  endogen- 
ous and  exogenous  origin.  This  pro- 
tective influence  of  maternal  milk  is 
clearly  defined  in  the  following  quota- 
tion from  Professor  William  Welch's 
Harvey  Lecture:  "It  is  an  important 
function  of  the  mother  to  transfer  to 
the  suckling,  through  her  milk,  immu- 
nizing bodies,  and  the  infant's  stomach 
has  the  capacity,  which  is  afterward  lost, 
of  absorbing  these  substances  in  active 
state.  The  relative  richness  of  the  suck- 
ling's blood  in  protective  antibodies,  as 
contrasted  with  the  artificially  fed  in- 
fant, explains  the  greater  freedom  of 
the  former  from  infectious  diseases." 
Striking  proof  of  this  is  afforded  by  the 
fact  that  during  the  siege  of  Paris,  in 
1870-71,  according  to  J.  E.  Winters 
("Practical  Infant  Feeding,"  p.  6), 
"while  the  general  mortality  was  dou- 
bled, that  of  infants  was  lowered  40  per 
cent,  owing  to  mothers  being  driven  to 
suckle  their  infants." 

Childhood.  —  The  predilection  of 
children  to  certain  infectious  diseases 
obviously  indicates  that  it  is  not  only  in 
infancy  that  vulnerability  to  these  dis- 
orders exists ;  it  exposes  life  during  the 
first  decade,  and  more,  of  the  child's  ex- 
istence. If,  then,  in  the  infant  the  ma- 
ternal milk,  as  Welch  says,  protects  the 
suckling  against  such  diseases,  at  least 
to  a  considerable  extent,  we  must  con- 
clude that  the  same  underlying  cause  of 
vulnerability  persists  several  years,  i.e., 
until  itdias  in  some  way  been  overcome. 
The  adrenals  acquire,  with  other  or- 
gans, the  power  to  supplant  the  mother 
in  contributing  antitoxic  bodies  to  the 


blood ;  they  supply  internal  secretions 
which  fulfill  this  role. 

These  facts  point  to  the  adrenals  as 
at  least  prominent  organs  among  those 
whose  inadequate  development  explain 
the  special  vulnerability  of  children  to 
certain  infections,  the  "children's  dis- 
eases." It  becomes  a  question  now 
whether  there  are  degrees  of  this  hypo- 
adrenia  which  render  the  child  more  or 
less  liable  to  infection. 

That  degrees  of  hypoadrenia  exist  in 
children  is,  in  reality,  a  famifiar  fact  to 
every  physician  when  the  signs  of  this 
condition  are  placed  before  him.  The 
ruddy,  warm,  hard-muscled,  heavy,  out- 
of-door,  romping  child  with  keen  appe- 
tite and  normal  functions,  is  one  in 
whom  the  adrenals  are  as  active  as  the 
development  commensurate  with  its  age 
will  permit.  He  is  ruddy  and  warm  be- 
cause oxidation  and  metabolism  are  per- 
fect and  -the  blood-pressure  sufficiently 
high  to  keep  the  peripheral  tissues  well 
filled  with  blood;  his  muscles,  skeletal, 
cardiac  and  vascular,  are  strong  because, 
in  addition  to  being  well  nourished,  they 
are  exercised  and  well  supplied  with  the 
adrenal  secretion,  which,  as  shown  by 
Oliver  and  Schafer,  sustains  muscular 
tone.  As  normal  outcome  of  this  state, 
we  have  constant  stimulation  of  the 
functional  activity  of  the  adrenals.  The 
muscular  exercise  and  maximum  food- 
intake  involve  a  demand  for  increased 
metabolism  and  oxidation,  and  the  re- 
sulting greater  output  of  wastes  imposes 
upon  the  adrenals,  as  participants  in  the 
oxidation  and  autoprotective  processes, 
greater  work,  more  active  growth  and 
development,  with  increase  of  defensive 
efficiency  as  normal  result. 

The  pale',  emaciated,  or  pasty  child, 
with  cold  hands  and  feet,  flabby  mus- 
cles, whose  appetite  is  capricious  or  de- 
ficient— the    pampered    house-plant    so 


458 


ADRENALS,    DISEASES    OF    (SAJOUS). 


often  met  among  the  rich — represents 
the  converse  of  the  healthful  child  de- 
scribed, just  as  does  the  ill-fed,  perhaps 
overworked,  child  of  the  slums.  The 
emaciation,  the  cold  extremities,  indi- 
cate deficient  oxidation,  metabolism  and 
nutrition  owing  to  the  torpor  of  the  ad- 
renal functions ;  the  pallor  is  mainly  due 
to  a  deficiency  of  the  adrenal  principle 
in  the  blood  and  to  the  resulting  low 
blood-pressure,  which  entails  retroces- 
sion of  the  blood  from  the  surface. 
This  child  is  not  ill,  but  the  hypoadrenia 
which  prevails  normally,  owing  to  the 
undeveloped  state  of  its  adrenals,  is  ab- 
normally low,  and  it  is  vulnerable  to 
infection. 

That  all  conditions  which  in  the  adult 
tend  to  produce  functional  hypoadrenia 
affect  the  child  at  least  to  the  same  ex- 
tent, is  self-evident. 

Adult  Age.' — As  in  the  child,  the  ad- 
renals may  be  inherently  weak.  Such 
subjects  do  not,  as  in  hypothyroidia, 
show  signs  of  myxedema ;  but  their  cir- 
culation and  heart  action  are  feeble,  they 
tend  to  adiposis,  and  show  other  signs 
of  hypoadrenia.  I  have  witnessed  sug- 
gestive bronze  spots  in  such  cases.  As 
a  rule,  however,  the  development  of  the 
adrenals  in  adults  is  an  accomplished 
fact — as  also  that  of  their  coworkers  in 
the  immunizing  process,  the  thyroid  and 
pituitary,  we  shall  see.  The  adrenals, 
fully  capable  of  sustaining  oxidation 
and  metabolism,  are  able  to  defend  the 
organism  adequately ;  indeed,  they  do 
more :  by  sustaining  oxidation  and  met- 
abolism up  to  its  highest  standard  in  all 
organs,  they  also  preserve  the  efficiency 
of  all  other  defensive  resources,  includ- 
ing phagocytosis,  with  which  the  body  is 
endowed  to  their  highest  level.  On  the 
whole,  the  normal  adult  zvhose  adrenals 
functionate  normally  is  relatively  resist- 
ant to  infection.    The  infrequency  with 


which  we  are  infected,  notwithstanding 
daily  exposure  in  our  professional  work, 
attests  to  this  fact. 

Functional  hypoadrenia  appears,  how- 
ever, when,  irrespective  of  any  disease, 
and  as  a  result  of  the  vicissitudes  of  our 
existence,  the  adrenals  are  subjected  to 
abnormal  secretory  activity. 

Fatigue  is  a  prominent  factor  in  this 
connection.  Mosso's  ergograph  shows 
clearly  the  functional  efficiency  of  the 
forearm.  If  by  means  of  this  instru- 
ment we  compare  the  muscular  power 
of  a  case  of  Addison's  disease  with  that 
of  any  other  kind  of  sufferer,  whose 
muscles  are  organically  normal,  a  strik- 
ing difference  will  be  noticed :  signs  of 
fatigue  appear  very  soon,  and  muscular 
impotence  asserts  itself  where  an  ad- 
vanced case  of  tuberculosis,  for  exam- 
ple, will  be  able  to  show  appreciable 
strength.  Intense  asthenia  is,  in  fact,  a 
symptom  of  Addison's  disease  almost 
as  characteristic  as  the  bronze  spots.  It 
is  as  pre-eminent  after  experimental  re- 
moval of  both  adrenals.  This  harmo- 
nizes with  Oliver  and  Schafer's  demon- 
stration of  the  influence  of  the  adrenal 
secretion  over  muscular  tone.  Many 
other  proofs  could  be  adduced  to  show 
that  there  is  a  close  relationship  between 
fatigue  and  the  functions  of  the  ad- 
renals. The  pale  and  drawn  face  of  an 
exhausted  man,  the  readiness  with  which 
he  suffers  from  the  effects  of  cold  and 
exposure,  especially  in  the  intestines,  are 
familiar  features  of  daily  life. 

The  unusual  prevalence  of  disease 
among  soldiers  in  the  field  is,  of  course, 
partly  due  to  the  defective  sanitation 
that  a  campaign  entails ;  but  fatigue — 
particularly  that  due  to  heavy  march- 
ing, carrying  heavy  accoutrements — is, 
in  my  opinion,  an  important  predispos- 
ing cause,  through  its  influence  upon  the 
adrenals.     Not  only  are  these    organs 


ADRENALS,    DISEASES    OF    (SAJOUS). 


459 


called  upon  to  sustain  general  oxidation 
and  metabolism  at  a  rate  exceeding  by- 
far  that  which  amply  suffices  for  normal 
avocations,  but  the  fact  that,  as  shown  by 
Abelous  and  Langlois  {loc.  cit.),  they 
also  serve  to  destroy  the  toxic  products 
of  muscular  activity,  constitute  another 
cause  of  drain  upon  their  secretory  re- 
sources. "Fatigue,"  write  Morat  and 
Doyon  (Traite  de  Physiologic,"  Art. 
"Secretions  Internes,"  p.  441,  1904),  re- 
ferring to  experimental  fatigue  in  ani- 
mals deprived  of  their  adrenals,  "has  an 
aggravating  influence,  as  first  indicated 
by  Abelous  and  Langlois,  and  confirmed 
by  Albanese  and  all  authors.  Hultgren 
and  Andersson  have  even  observed 
sudden  death  as  a  result  of  powerful 
movements  of  the  body." 

Debility  from  any  source,  starvation, 
loss  of  blood,  etc.,  as  efficiently  renders 
the  body  vulnerable  to  disease :  "Com- 
bine toxin  and  antitoxin,  and  inject  the 
mixture,"  writes  Professor  Charrin 
("Les  Defenses  Naturelles  de  I'Organ- 
isme,"  p.  63,  Paris,  1898);  "no  harm 
will  follow.  But  weaken  the  animal  by 
starvation  or  slight  bleeding  and  admin- 
ister the  same  injection;  death  will  fol- 
low wath  all  the  signs  of  poisoning  by 
the  toxin,  with  congested  adrenals." 
,  ,  ,  "That  relations  exist  between 
the  adrenals  and  infection,"  urges  the 
same  authority,  "is  today  an  incontro- 
vertible fact."  It  follows,  therefore, 
that  hypoadrenia  from  any  source 
should  render  the  body  vulnerable  to 
disease.  Deficient  food,  excessive  work, 
that  of  the  sweat-shops  for  example,  ac- 
count for  much  of  the  predilection  of 
our  slums  as  foci  of  disease,  their  filth 
nurturing  the  appropriate  germs. 

Masturbation  and  excessive  venery 
are  important  morbid  factors  in  this 
connection.  The  pallor  and  asthenia 
witnessed  in  these  cases,  so  far  unex- 


plained, can  rea(Hly  be  accounted  for  if, 
as  I  believe,  the  liquid  portion  of  the 
semen  is  rich  in  adrenal  principle.  This 
is  suggested  by  the  fact  that  spermin, 
the  purest  of  testicular  preparations, 
gives  the  same  tests  and  acts  precisely 
as  does  the  adrenal  principle.  The 
latter  is  an  oxidizing  body  acting  cata 
lytically;  it  resists  all  temperatures  up 
to  and  even  boiling;  it  is  insoluble  in 
ether  and  practically  insoluble  in  abso- 
lute alcohol,  and  gives  the  guaiac,  Flor- 
ence, and  other  hemin  tests.  Now,  sper- 
min not  only  raises  the  blood-pressure, 
slows  the  heart  and  produces  all  other 
physiological  effects  peculiar  to  the  ad- 
renal principles,  but  its  solubilities  are 
the  same ;  it  gives  the  samie  tests ;  it  re- 
sists boiling.  Moreover,  it  is  regarded 
in  Europe  as  a  powerful  "oxidizing 
tonic,"  and  has  been  found  equally  use- 
ful in  disorders  in  which  adrenal  prepa- 
rations had  given  good  results.  The  in- 
ference that  spermin  consists  mainly  of 
the  adrenal  product  suggests  that  it 
should  not  be  regarded  as  specific  to  the 
testes,  but,  instead,  a  constituent  of  the 
blood  at  large;  not  only  did  this  prove 
to  be  the  case,  but  it  was  found  in  the 
blood  of  females  as  well  as  in  that  of 
males. 

Old  Age.— Perpetual  life  would  doubt- 
less be  ours  were  it  not  that  all  living 
organic  matter  is  subjected,  after  more 
or  less  precarious  periods  of  growth  and 
adult  existence,  to  one  of  decline  and 
final  disintegration.  This  applies  par- 
ticularly to  the  adrenals,  if  their  func- 
tions are,  as  I  hold,  to  sustain  oxidation 
and  metabolism,  the  fundamental  pro- 
cesses of  the  living  state.  Indeed,  the 
senile  state  may  be  said  to  be  as  evident 
in  these  organs  as  it  is  in  the  features 
of  the  aged. 

Series   of   corrosion   preparations,   of 
the  veins  of  the  left  adrenal  in  different 


460 


ADRENALS,    DISEASES    OF    (SAJOUS). 


people,  aged,  respectively,  22,  30, 
80,  and  82,  using  the  same  inject- 
ing substance  and  technique.  They 
showed  conclusively  that  the  vascular 
system  of  the  adrenals  becomes 
steadily  smaller  as  adult  age  wanes, 
being  greatly  shrunken  in  old  people. 
Landau  (St.  Petersb.  med.  Woch., 
June  14,  1908). 

According  to  Landau  (St.  Petersb. 
med.  Woch.,  June  14,  1908),  Ecker, 
Henie,  and  von  Kolliker  found  that  fat 
occurred  in  increasing  quantities  in  the 
adrenal  cortex  \s  age  advanced,  while 
Hultgren  and  Andersson  found  fibrous 
tissue  between  the  cortex  and  medulla 
in  very  old  animals.  Minervini  (Jour. 
d'anat.  et  de  physiol.,  pp.  449  and  639, 
1904)  found  a  similar  condition  in  the 
medulla  of  aged  individuals.  Dostojew- 
ski,  moreover,  observed  a  marked — oc- 
casionally very  great — reduction  in  the 
size  of  the  adrenals  in  the  aged.  Rolles- 
ton  (Lancet,  Mar.  23,  1895)  has  also 
called  attention  to  this  fact. 

Landau  studied  the  influence  of 
age  on  the  vessels,  large  and  small, 
of  the  adrenals,  adopting  for  the  pur- 
pose a  process  introduced  by  Rauber 
and  applied  by  many  others,  including 
Bezold,  Hyrtl,  and  Lieberkiihn,  to  the 
study  of  other  organs,  viz.,  injection  of 
the  vessels  with  some  hardening  sub- 
stance, and  the  subsequent  use  of  a  cor- 
rosion method  to  destroy  the  paren- 
chyma. The  adrenals  receiving  their 
blood  through  a  number  of  small  arte- 
ries, the  adrenal  vein,  which  contains  no 
valves,  was  used  for  the  injection.  The 
annexed  plate  shows  the  result.  The 
vessels,  and  therefore  the  adrenals,  are 
well  developed  and  in  full  bloom,  as  it 
were,  in  the  adrenals  of  the  three  young 
adults,  while  those  of  the  aged  are 
shrunken  and  correspondingly  deficient 
as  blood-channels — a  certain  index  of 
the  lowered  activity  of  the  adrenal  func- 


tions, and,  through  these,  of  the  vita! 
process  they  sustain. 

The  asthenia  of  old  age  thus  finds  a 
normal  explanation  in  the  defective  sup- 
ply of  adrenal  secretion — precisely  as  it 
does  in  Addison's  disease.  In  fact,  Rol- 
leston  states  that  atrophy  of  the  glands 
in  the  young  may  produce  this  disease. 
Lorand  ("Old  Age  Deferred,"  Am.  ed., 
p.  Ill,  1910),  in  h-is  recently  published 
book  on  old  age,  urges,  in  fact,  that  "old 
age  is  caused  by  degeneration  of  the 
ductless  glands,  and  that  there  exists  a 
condition  of  autointoxication  in  old  age" 
quite  in  keeping,  I  may  add,  with  a  de- 
cline of  the  antitoxic  power  shown  by 
the  adrenals.  Lorand,  who  has  ante- 
dated others  in  showing  the  influence 
of  the  ductless  glands  upon  old  age,  has 
found  his  views  confiremed  by  Camp- 
bell (Lancet,  July,  1905),  Pineles,  Sir 
Herman  Weber,  and  also — though  he 
denies  a  relationship  between  old  age 
and  myxedema — Metcnnikoff. 

In  his  closing  remarks  on  the  causa- 
tion of  old  age,  Lorand  remarks :  "It  is 
evident  from  the  above  considerations 
that  all  hygienic  errors,  be  they  errors 
of  diet  or  any  kind  of  excess,  will  bring 
about  their  own  punishment,  and  that 
premature  old  age,  or  a  shortened  life, 
will  be  the  result.  In  fact,  it  is  mainly 
our  fault  if  we  become  senile  at  60  or 
70,  and  die  before  90  or  100."  Hence 
the  motto  of  his  title  page : — 

"Man  does  not  die. 
He  kills  himself." 

— Seneca. 

In  the  light  of  the  data  I  have  sub- 
mitted, however,  it  is  clear  that  the  le- 
sions to  which  the  adrenals  are  subjected 
during  infections  and  autointoxication, 
from  birth  to  the  last  day  of  life,  do 
greatly  shorten  it  by  limiting  the  func- 
tional area  of  the  organs  through  the 
local  fibrosis  they   entail.     It  is  quite 


ADRENALS,    DISEASES    OF    (SAJOUS). 


461 


probable,  in  fact,  that  centenarians  owe 
their  prolonged  longevity  mainly  to  in- 
tegrity of  their  adrenals. 

Hygiene,  and  particularly  those  of  its 
divisions  which  bear  directly  upon  the 
prevention  of  infectious  diseases,  thus 
asserts  itself  as  one  of  the  most  useful 
of  our  sciences  in  another  direction, viz., 
that  of  preserving  the  organism  against 
those  diseases  which,  seemingly  benign 
because  they  are  recovered  from,  mea- 
sles for  example,  in  the  end  shorten  our 
existence  by  compromising  the  integrity 
of  the  organs  which  sustain  the  vital 
process  itself. 

Prophylaxis  and  Treatment. — 
Though  we  are  dealing  with  depraved 
states  of  a  physiological  condition,  we 
cannot  but  regard  them  as  abnormal  m 
the  sense  that  we  deem  adynamia  abnor- 
mal, and,  therefore,  susceptible  to  reme- 
dial measures.  Indeed,  there  is  much 
that  can  be  done  in  each  of  the  three 
forms  of  functional  hypoadrenia  de- 
scribed. 

In  the  infant  we  should,  by  every  pos- 
sible means,  prevent  infection  or  intoxi- 
cation to  preserve  the  integrity  of  their 
adrenals  and  other  autoprotective  or- 
gans. The  key  of  the  whole  situation 
lies  in  the  fact  that,  as  Ruhrah  states, 
"nearly  all  the  cases  and  nearly  all  the 
deaths  are  in  bottle-fed  babies."  Physi- 
cians are,  as  a  rule,  entirely  too  ready  to 
yield  to  the  demands  of  social  and  other 
claims  put  forth  by  mothers  who  do  not 
wish  to  nurse  their  offsprings.  The  re- 
sponsibility assumed  by  both  mother 
and  physician  under  these  circumstances 
is  overlooked.  I  cannot  but  hope  that  if 
this  continues,  and  the  sacrifice  of  count- 
less infants  proceeds,  laws  may  be  en- 
acted-to  prevent  it  by  imposing  upon  the 
physician  the  duty  of  submitting  to  the 
State  authorities  a  certificate  in 'which 
sound  reasons  shall  alone  account  for 


his  consent  to  a  departure  from  nature's 
methods  which  entails  deaths  untold.  J. 
Lewis  Smith  states  that  the  death  rate 
among  foundlings  in  New  York  City 
reached  almost  100  per  cent,  until  wet- 
nurses  were  provided.  Men  such  as 
Jacobi,  Winters,  and  many  French  au- 
thorities have  written  forcibly  upon  this 
subject,  but  seemingly  to  no  avail.  The 
holocaust  continues. 

Experimental  research  in  the  same 
direction  has  only  served  to  emphasize 
the  all-important  prophylactic  value  of 
maternal  milk.  As  L.  T.  de  M.  Sajous 
(Univ.  of  Penna.  Med.  Bull.,  June, 
1909)  states:  "That  milk  is  capable  of 
conveying  antitoxic  substances  after 
these  have  been  injected  into  the  mother 
has  been  known  for  a  number  of  years. 
In  1892  Ehrlich  and  Brieger  demon- 
strated this  fact  in  their  experiments  on 
mice.  The  offspring  of  non-immune 
mice  werfe  suckled  by  other  mice  which 
had  been  immunized  against  the  actions 
of  certain  poisons.  It  was  found  that 
the  young  were  thereby  rendered  im- 
mune to  the  poisons  employed,  viz., 
ricin,  abrin,  and  tetanus  toxin.  This  im- 
munity steadily  increased  during  the 
period  of  lactation,  persisted  for  some 
time  after,  and  then  gradually  disap- 
peared. Ehrlich  thus  showed  that  a 
passive  immunity  was  created  in  the 
young  by  the  absorption  of  milk  from 
an  immune  adult,  and  even  went  so  far 
as  to  assert  that  all  so-called  heredity 
immunity  was,  in  reality,  of  the  passive 
variety,  being  transmitted  during  lacta- 
tion and  not  inherent  in  the  offspring 
itself. 

"This  transmitted  immunity  has  been 
shown  to  occur  in  various  other  animals. 
Thus,  in  1893,  Popoff  showed  that  im- 
munity against  cholera  could  be  trans- 
mitted through  cows'  milk.  He  injected 
bouillon  cultures  into  the  peritoneal  cav- 


462 


ADRENALS,    DISEASES    OF    (SAJOUS). 


ity  of  a  cow,  and  later  injected  into 
guinea-pigs  from  2  to  10  c.c.  of  the 
cow's  milk.  The  guinea-pigs  become 
immune  against  cholera.  The  same  ob- 
server noted  also  that,  when  the  milk 
was  boiled  before  injecting  it,  no  immu- 
nity was  produced.  Kraus  showed  that 
the  milk  of  goats  immunized  by  injec- 
tions of  'typhus-coli  bacilli'  and  cholera 
organisms  had  protective  and  aggluti- 
nating properties.  He  also  ascertained 
that  the  relative  proportion  of  aggluti- 
nating substance  present  in  milk  to  that 
contained  in  the  serum  was  as  1  to  10. 
Taking  up  the  subject  from  the  stand- 
point of  tuberculosis,  Figari  showed,  in 
1905,  that  the  agglutinins  and  antitoxins 
of  this  disease  appeared  in  the  milk  of 
cows  and  goats  that  had  been  actively 
immunized  against  it.  In  another  series 
of  experiments  he  fed  the  milk  of  im- 
mune cows  to  a  number  of  rabbits,  and 
in  others  injected  it  subcutaneously.  In 
both  cases  these  animals,  thus  passively 
immunized,  were  found  to  transmit  to 
their  young,  by  their  milk,  the  aggluti- 
nins and  antitoxins  of  tuberculosis. 

"Evidence  is  not  lacking  of  the  trans- 
mission of  antitoxic  substances  through 
human  milk.  It  has  long  been  known 
that  infants  below  one  year  of  age  were 
but  slightly  susceptible  to  certain  infec- 
tious diseases,  and  in  particular  scarlet 
fever,  diphtheria,  measles,  and  mumps. 
In  fact,  it  was  an  attempt  to  throw  some 
light  on  this  subject  that  Ehrlich  per- 
formed his  classic  experiments  on  mice 
in  1892.  Four  years  later  Schmid  and 
Pflanz  performed  some  interesting  ex- 
periments on  guinea-pigs.  Into  some  of 
the  animals  they  injected  blood-serum 
derived  from  human  blood  which  was 
taken,  at  the  time  of  delivery  of  her 
child,  from  a  woman  to  whom  had  been 
administered  diphtheria  antitoxin.  Into 
other  guinea-pigs    they    injected    milk 


from  the  same  woman.  The  animals 
were  then  given  injections  of  the  ordi- 
narily fatal  dose  of  diphtheria  toxin. 
From  the  results  obtained  the  investiga- 
tors concluded  (1)  that  antitoxin  sub- 
stances found  in  the  blood  of  parturient 
women  exist  also  in  the  milk;  (2)  that 
the  quantity  of  antitoxic  substances  ex- 
creted with  the  milk  is  much  less  than 
that  found  in  the  blood.  Similarly,  in 
1905,  la  Torre  injected  diphtheria  anti- 
toxin in  several  wet-nurses,  and  noted 
the  antitoxic  power  resulting  in  the 
blood  of  the  nurslings  by  injecting  meas- 
ured amounts  of  this  blood  mixed  with 
diphtheria  toxin  into  guinea-pigs.  He 
was  able  to  satisfy  himself  that  a  pass- 
age of  the  antibodies  occurred  in  small 
amounts  into  the  blood  of  the  infants. 

"These  experiments  show,  then,  that 
antibodies  injected  into  the  mother  are 
transmitted  to  the  offspring.  This  being 
the  case,  it  is  but  reasonable  to  expect 
that  some  of  the  protective  substances 
ordinarily  present  in  the  normal  moth- 
er's blood  should  likewise  reach  the 
child  through  the  milk.  Experiments 
have  shown  this  also  to  occur.  Moro 
found  that  the  bactericidal  power  of  the 
blood-serum  in  breast-fed  children  was 
distinctly  greater  than  in  those  arti- 
ficially fed.  Further  confirmation  was 
afforded  by  the  fact  that  this  difference 
rapidly  disappeared  when  the  bottle-fed 
infants  were  put  back  to  the  breast." 

The  prevention  of  disease  in  the  in- 
fant is  raised  to  its  highest  standard  by 
maternal  lactation.  The  organisms  of 
its  gastrointestinal  canal  are  kept  under 
control;  the  barriers  to  infection  that 
the  respiratory  tract  and  pulmonary  al- 
veoli offer  are  well  armed  with  antitoxic 
bodies ;  the  blood  itself  is  destructive  to 
pathogenic  organisms,  and  the  infant  is 
thus  protected  against  those  diseases 
which,  even  if  recovered  from,  we  have 


ADRENALS,    DISEASES    OF    (SAJOUS). 


463 


seen,  leave  enfeebling  lesions,  fatty  and 
fibrous  degeneration,  in  those  organs 
upon  which  his  health  in  after  years  and 
the  duration  of  his  life  depend. 

In  the  child  beyond  the  nursing  pe- 
riod the  problem  is  more  difficult.  The 
fatal  "second  summer"  recalls  the  sins 
of  the  milkman,  the  filth  of  the  cowshed, 
and  of  the  vessels  in  which  the  milk  is 
transported  and  kept  amply  long  enough 
to  favor  the  growth  of  the  oft-present 
Shiga  bacillus,  the  virulent  Bacillus  coll, 
and  even  at  times  the  streptococcus. 
The  correction  of  these  and  many  other 
factors  replete  with  danger  to  the  child, 
and  which  surround  it  on  all  sides,  of- 
fers the  only  resources  to  diminish  not 
only  the  mortality  of  children's  diseases, 
but  their  occurrence,  besides  safeguard- 
ing health  and  longevity  in  after  years. 
The  good  already  done  by  our  profes- 
sion in  this  direction  is  incalculable. 
Briefly,  public,  home,  and  school  hy- 
giene, in  the  light  of  the  facts  I  have 
submitted,  not  only  serves  to  protect  life 
for  the  moment  when  the  child  is  con- 
cerned, but  its  entire  career  as  a  health- 
ful individual,  while  enhancing  greatly 
his  chances  for  a  long  life. 

It  now  becomes  a  question  whether 
our  resources  are  such  as  to  enable  us 
to  raise,  where  functional  hypoadrenia 
exists,  the  autoprotective  resources  of 
the  child,  sufficiently,  perhaps,  to  enable 
it  to  resist  infection  successfully.  The 
influence  of  many  toxins  and  drugs  on 
the  adrenals  points  clearly  to  overactiv- 
ity under  their  influence.  In  1903  ("In- 
ternal Secretions,"  vol.  i)  I  referred  to 
mercury  as  occupying  "a  high  position 
among  the  stimulants  of  the  adrenal  sys- 
tem." Now,  C.  R.  Illingworth  ("The 
Abortive  Treatment  of  Specific  Febrile 
Disorders,"  etc.,  London,  1888)  and 
others  have  found  the  biniodide  of 
mercury  extremely  efficient  in  aborting 


scarlatina,  diphtheria,  measles,  variola, 
varicella,  pertussis,  parotitis,  and  many 
other  infections.  The  great  vogue  of 
calomel  among  the  physicians  of  the 
past  generation  may  have  found  its 
raisoii  d'etre  precisely  in  just  such  an 
action — which  I  have  myself  observed. 
Arsenic  is  a  familiar  agent  in  the  abort- 
ive treatment  of  malaria  in  Africa,  and, 
as  Surgeon-General  Boudin  states,  in 
many  other  diseases.  The  remarkable 
results  of  Petresco  with  large  doses  of 
infusion  of  digitalis  in  pneumonia  have 
only  been  tentatively  explained.  But  if 
we  realize  that  division  of  the  path  to 
the  adrenals  arrests  and  prevents  the 
effects  of  digitalis,  as  is  now  well 
known,  there  is  good  ground  for  the  be- 
lief that  the  prevailing  conception  of  the 
action  of  this  drug  is  erroneous,  and  that 
it  is  by  stimulating  the  adrenals  that  it 
acts,  at  least  in  part.  In  view  of  the  im- 
munizing action  of  the  adrenals,  there- 
fore, we  can  realize  how  digitalis  could 
be  of  use  in  this  infectious  disease,  and 
how  it  might  prove  useful  in  aborting 
any  pulmonary  disorder  due  to  patho- 
genic organisms. 

Very  remarkable  in  this  connection  is 
the  action  of  thyroid  gland  1  grain  (0.06 
Gm.),  adrenal  gland  2  grains  (0.12 
Gm.),  and  Blaud's  pill  1  grain  (0.06 
Gm.)  in  a  capsule  three  times  daily, 
previously  referred  to.  Given  during 
meals  to  a  debilitated  child  of  10  or  12 
years,  it  seems  promptly  to  start  the 
vital  machinery  on  a  new  lease  of  life — 
where,  of  course,  the  demands  of  hy- 
giene are  adequately  met.  Meat  is  of 
value  here,  while  milk,  the  fluid  portion 
of  which  gives  the  test  for  oxidases, 
and  which,  as  I  have  shown  elsewhere, 
depends  upon  the  adrenal  secretion  for 
its  ferment  (adrenoxidase)  is  also  of 
great  value.  Digitalin  or  strychnine 
in  small   doses  is  added  if  the  heart 


464 


ADRENALS,    DISEASES    OF    (SAJOUS). 


is  weak  or  to  increase  the  oxygen  in- 
take. All  these  agents  tend,  by  keeping 
up  a  slight  hyperemia  of  the  adrenals 
(and  of  the  other  organs  acting  in  con- 
junction with  it),  to  augment  the  effi- 
ciency of  the  child's  defensive  resources. 

In  the  adult  functional  hypoadrenia 
may  have  persisted  from  childhood. 
Here  the  measures  just  suggested  for 
children  apply  as  well  not  only  as  pre- 
ventives where  infection  threatens,  or 
as  abortive  treatment,  but  also  to  raise 
the  efficiency  of  the  adrenals  and  the 
general  health  of  the  individual  to  the 
normal  plane.  It  is  probable  that  most 
tonics  exert  their  beneficial  influence 
through  the  adrenals.  That  "tonic" 
doses  of  mercury,  i.e.^  minute  doses,  are 
efficient  is  well  known;  we  have  seen 
that  it  is  a  powerful  adrenal  stimulant. 
In  toxic  doses,  in  fact,  as  observed  by 
Moline  (Bull.  gen.  de  therap.,  Apr.  8, 
1906),  it  causes  intense  congestion  and 
even  hemorrhage  of  the  adrenals. 

While  there  is  no  doubt  that  meat  in 
excess  is  harmful,  it  is  undoubtedly 
true  that,  as  Lorand  (he.  cit.,  p.  313) 
states,  undernutrition  through  lack  of 
the  necessary  proteids  in  the  diet  in- 
creases the  habiHty  to  infection,  as  I 
several  years  ago  pointed  out,  Lorand 
refers  to  personal  cases  of  tubercu- 
losis arising  from  a  purely  vegeta- 
rian diet.  On  the  other  hand,  Richet 
and  Hericourt  (Lancet,  Jan.  7,  1911) 
obtained  remarkable  effects  from  a  diet 
of  raw  meat  in  enabling  animals  to  re- 
sist tubercle  infection  by  inoculation, 
and  ravv^  meat  has  become  an  important 
factor  in  the  treatment  of  this  disease. 
Grawitz  (Klinische  Pathologic  des 
Blutes,  3d  ed.,  1906)  also  found  that  a 
purely  vegetarian  diet  predisposed  to 
anemia.  We  have  seen  that  the  ad- 
renals supply  the  blood  its  albuminous 
hemoglobin,  a  deficiency  of  which  is  an 


important  feature  of  anemia.  Did  we 
live  where  pathogenic  bacteria  do  not 
flourish,  we  might  safely  undertake  to 
adopt  vegetarian  principles;  but  a  rea- 
sonable amount  of  meat,  by  keeping  our 
autoprotective  organs,  and  particularly 
the  adrenals,  active,  serves  a  very  useful 
purpose. 

The  influence  of  excessive  fatigue  on 
the  adrenals,  we  have  seen,  is  such  as 
to  weaken  greatly  their  functional  ac- 
tivity and,  therefore,  the  oxygenizing 
and  immunizing  functions  of  the  blood. 
The  main  harmful  feature  in  this  con- 
nection is  the  relative  deficiency  of  rest, 
which  means,  from  my  viewpoint,  the 
inadequate  opportunity  afforded  the  ad- 
renals to  recuperate.  This,  of  course, 
should  be  proportionate  to  the  amount  of 
strain  imposed  upon  these  organs,  and 
the  resistance  of  which  they  are  capa- 
ble. It  is  probably  owing  to  lack  of  this 
that  apparently  strong  men  are  often 
the  first  to  "give  out"  in  forced  marches. 
The  physical  examination  being  based 
mainly  upon  the  status  presens,  and  the 
adrenals  being  necessarily  (for  we  are 
now  dealing  with  a  new  line  of  thought) 
overlooked  as  factors,  there  is  marked 
inequality  in  the  resistance  of  the  men 
to  strain.  This  applies  as  well  to  the 
pathogenesis  of  chronic  disorders.  In 
a  personal  analysis  of  40  cases  of  hay 
fever,  for  instance,  the  severity  of  the 
disease  corresponded  to  a  considerable 
degree  with  the  number  of  children's 
diseases  the  patient  had  had,  the  worst 
cases  having  had  six  of  these  diseases 
in  comparatively  quick  succession. 

This  suggests  the  need  of  ascertain- 
ing the  number  and  severity  of  chil- 
dren's and  other  diseases  to  which  the 
recruit  has  been  subjected  and  to  add 
this  factor  to  others  in  deciding  upon 
his  admission  to  the  service  or  the  arm 
to  which  he    is    to  be  assigned.     The 


ADRENALS,    DISEASES    OF    (SAJOUS). 


465 


mounted  man  suffers  less  from  actual 
fatigue  than  the  infantryman,  who  must 
carry  his  accoutrements,  arms,  car- 
tridges, etc.,  aggregating  in  some  armies 
as  much  as  70  pounds.  When,  besides, 
defective  or  poor  food,  impure  water, 
exposure,  etc.,  and  other  frequent  ac- 
companiments of  a  campaign  are  taken 
into  account,  one  need  not  wonder  that 
disease  is  a  far  greater  factor  as  causes 
of  debility  and  death  than  wounds. 

Briefly,  fatigue  should  be  considered, 
owing  to  its  inhibiting  influence  on  the 
adrenals  and  the  immunizing  process  in 
which  they  take  part,  as  an  important 
predisposing  cause  of  disease.  The  pe- 
riods of  rest  should  be  so  adjusted, 
therefore,  as  to  counteract  this  by  far 
the  most  destructive  factor  of  active 
warfare.  In  civil  life,  such  hardships 
are  seldom  endured,  but  here,  likewise, 
much  could  be  done  to  prevent  infection 
by  means  calculated  to  insure  the  func- 
tional integrity  of  the  adrenals. 

To  stimulate  the  adrenal  functions 
when  marked  fatigue  prevails  would,  of 
course,  only  aggravate,  the  hypoadrenia 
after,  perhaps,  a  period  of  temporary 
betterment.  The  powdered  adrenal  sub- 
stance should,  on  the  other  hand,  judg- 
ing from  the  effects  of  injections  of  ad- 
renal extracts  in  experimentally  fatigued 
animals,  serve  a  useful  purpose. 

In  old  age  the  ductless  glands  assume 
such  importance  that  a  valuable  work 
has  been  written  by  Lorand  ("Old  Age 
Deferred,"  F.  A.  Davis  Co.,  Phila., 
1910)  to  indicate  how  the  functional  ac- 
tivity of  these  organs  could  be  preserved 
in  order  to  retard  the  ravages  of  age 
beyond  the  fifth  decade,  while  prolong- 
ing life.  The  reader  is  therefore  re- 
ferred to  Dr.  Lorand's  volume  for  a 
mass  of  information  which  cannot  be 
considered  here. 

The  adrenals,  as  shown  by  the  plate 


opposite  page  460,  are  deficient  in  circu- 
latory activity,  and,  therefore,  unable  to 
sustain  functional  activity  of  all  organs 
up  to  its  former  standard.  It  becomes 
a  question  whether,  realizing  this  fact, 
we  should  by  artificial  means  excite  the 
adrenals  to  greater  activity.  That  such 
a  step  might  shorten  life  instead  of  pro- 
longing it,  is  probable.  In  the  first  place, 
the  frequent  presence  of  arteriosclerosis 
in  the  aged  counsels  prudence ;  in  the 
second  place,  to  activate  the  adrenals 
would  only  hasten  their  degeneration  by 
imposing  a  greater  wear  and  tear  upon 
them.  Drugs  capable  of  enhancing  ad- 
renal activity  had,  therefore,  better  be 
avoided  in  the  aged. 

Far  better  is  it  to  compensate  for  the 
loss  of  efficiency  of  the  adrenals  by  sup- 
plying to  the  blood,  through  a  suitable 
diet,  substances  which  contain  the  ad- 
renal principle.  If  my  opinion  that  sper- 
min  owes  its  virtues  to  the  adrenal  prin- 
ciple it  contains  is  warranted,  we  can 
understand  why  Brown-Sequard  reju- 
venated himself  by  means  of  testicular 
juice  injections  (I  saw  him  at  the  time 
and  can  testify  to  its  wonderful  effects 
upon  him),  since  he  enriched  his  blood 
with  the  pabulum  of  oxidation,  met- 
abolism and  general  nutrition,  without 
impairing  his  adrenals.  With  advanced 
knowledge  we  need  not  follow  his  ex- 
ample. We  have  seen  that  milk  con- 
tains the  adrenal  principle,  and  that  all 
animal  tissues  owe  their  functional  ac- 
tivity to  its  presence.  In  milk,  butter- 
milk especially  (since  it  is  almost  pure 
plasma),  we  have  a  ready  and  inexpen- 
sive means  to  compensate  for  deficient 
adrenal  activity.  If  debility  and  other 
signs  of  functional  hypoadrenia  prevail, 
I  advocate  the  daily  addition  to  the  plain, 
though  varied,  diet  to  which  elderly  peo- 
ple should  restrict  themselves  of  the  ex- 
pressed juice  (uncooked)  of  one  pound 


1-30 


466 


ADRENALS,    DISEASES    OF    (SAJOUS). 


of  fresh  beef  daily,  taken  in  soup,  if  dis- 
tasteful otherwise,  and  salted  to  taste. 
This  is  a  powerful  agent  for  good  which 
is  well  borne  by  the  stomach,  and  which 
more  than  compensates  for  the  weak- 
ened adrenals,  since  it  rapidly  restores 
strength  and  vigor — provided,  of  course, 
harmful  influences  in  other  directions 
are  avoided,  and.  a  hygienic  mode  of  life, 
with  reasonable  out-of-door  exercise, 
prevails. 

In  matters  sexual,  aged  men  should 
be  extremely  reserved,  since  the  waste 
of  seminal  fluid  to  them  means  w'aste  of 
life  substance,  replaced  with  difficulty 
and  never  in  abundance. 

Case  of  total  absence  of  the  adrenals 
in  a  woman,  aged  52,  who,  in  Septem- 
ber, 1902,  noticed  that  her  hands  fre- 
quently became  cold  and  discolored.  In 
January,  1903,  the  joints  of  fingers  and 
wrists  became  stiff  and  swollen ;  during 
April  she  suffered  frcn  pleurisy,  and 
one  month  later  noticed  that  the  skin 
of  the  entire  body  was  becoming  darker 
(Addison's  disease),  the  abdomen  en- 
larged, and  she  discovered  a  slight  dis- 
charge from  the  umbilicus.  The  skin 
grew  darker  and  darker  (scleroderma). 
The  joints  of  the  fingers  and  wrists 
became  almost  immovable  and  several 
of  the  finger-joints  ulcerated,  attended 
with  a  purulent  discharge  (Raynaud's 
disease).  She  suffered  intensely  with 
the  pain,  cold  and  stiffness  in  all  the 
joints  of  the  extremities.  She  became 
emaciated  and  the  whole  integument  be- 
came dry,  hard,  and  cold. 

Under  treatment  with  desiccated  ad- 
renal immediate  improvement  was  no- 
ticed. The  ulcerated  joints  healed,  pain 
in  them  ceased,  and  they  became  more 
limber.  The  skin  softened  and  grew 
lighter.  Improvement  continued  for 
about  one  year  when  the  patient 
complained  that  the  po  der  disturbed 
her  stomach  and  refused  to  continue 
the  drug.  From  this  time  she  grew 
gradually  worse  and  the  previous  ul- 
cerated, stiff,  cold,  and  painful  condi- 
tion of  the  joints  returned,  associated 
with    the    increased    pigmentation    and 


hardness  of  the  skin.  She  died  sud- 
denly, December  14,  1906.  At  the 
autopsy  no  trace  of  the  adrenals  could 
be  found.  C.  R.  Love  (N.  Y.  Med. 
Jour.,  Jan.  29,  1910;  Jour.  Amer.  Med. 
Assoc,  Feb.  12,  1910). 

PROGRESSIVE  HYPOADRE- 
NIA. — In  this  condition,  local  lesions, 
tubercular,  syphilitic,  sclerous,  etc.,  pro- 
gressively inhibit  the  functions  of  the 
adrenals  until  they  fail,  destroying  life. 
Addison  s  disease,  treated  separately  on 
page  356  of  this  volume,  by  Professor 
J.  P.  Langlois,  of  Paris,  to  whose  labors 
I  have  repeatedly  referred  in  the  fore- 
going pages,  is  the  most  important  syn- 
drome of  this  group.  In  addition  is  the 
group  of  malignant  tumors  which, 
though  presenting  the  chief  phenomena 
of  the  former  and,  therefore,  those  of 
hypoadrenia,  include  various  symptoms 
peculiar  to  malignant  neoplasms  which 
warrant  the  recognition  of  an  autono- 
mous syndrome  complex. 

CANCER  OF  THE  ADRENALS. 
— Primary  malignant  tumors  of  the  ad- 
renals are  generally  regarded  as  very 
rare,  but  it  is  probable  that  when  the 
symptomatology  of  these  growths  will 
be  known  by  the  profession  at  large,  a 
certain  proportion  of  deaths  now  attrib- 
uted to  Addison's  disease  in  adults  and 
to  asthenic  disorders  in  children  w"ill  be 
found  to  be  due  to  this  class  of  growths. 
Addison,  in  fact,  included  these  neo- 
plasms among  the  etiological  factors  of 
the  disease  which  bears  his  name,  but 
it  is  now  plain  that  the  two  syndromes 
differ  in  many  respects,  and  that  the 
treatments  indicated — medical  in  the 
one  and  surgical  in  the  other — imposes 
the  need  of  recognizing  malignant  neo- 
plasms of  the  adrenals  as  distinct  mor- 
bid entities. 

VARIETIES.— Primary  malignant 
tumors  of  the  adrenals  are  of  the  va- 
rious forms  of  sarcoma,  those  most  fre- 


ADRENALS,    DISEASES    OF    (SAJOUS). 


467 


quently  met  with  and  which  occur,  in 
the  majority  of  instances,  in  infancy, 
childhood  and  adolescence;  carcinoma, 
which  occurs,  as  a  rule,  in  adults  or 
aged  subjects.  Among  the  rarer  varie- 
ties may  be  mentioned  the  malignant 
hypcrncpJiroma  and  a  class  of  tumors 
termed  by  Prudden  hcmorrliagic  ade- 
noma. 

The  sexes  are  affected  about  equally, 
but  they  appear  much  earlier  in  females 
than  in  males.  Carcinoma  may  develop 
from  hypernephroma. 

[Sixty-seven  collected  by  Ramsay  from 
literature,  including  30  of  sarcoma  and  37 
of  carcinoma.  This  would  tend  to  suggest 
that  the  two  forms  occur  about  evenly. 
C.  E.  DE  M.  S.] 

Primary  tumors  of  the  adrenals  are 
very  infrequent.  In  the  statistics  of 
the  Pathological  Institute  of  Geneva, 
out  of  7249  autopsies  performed  from 
Oct.  1,  1876,  to  Oct.  1,  1903,  the  pro- 
portion was  0.6  of  1  per  cent.  Dupraz 
(Revue  med.  de  la  Suisse  Romande, 
Mar.  20,  1906). 

Study  of  the  collection  of  kidney 
tumors  in  the  Jewish  Hospital  at 
Berlin,  103  in  all.  No  less  than  69 
.  belong  to  the  group  of  hypernephro- 
mas. In  two  the  writer  found  unmis- 
takable evidence  that  true  carcinoma 
had  developed  out  of  a  hyperne- 
phroma. Displaced  suprarenal  ger- 
minal matter  had  lodged  in  the  kid- 
ney in  early  embryonic  existence,  a 
hypernephroma  had  developed  from 
this,  and  the  carcinoma  from  the 
parenchyma  of  the  hypernephroma. 
The  writer  does  not  maintain  that 
embryonal  displacement  of  germinal 
matter  is  the  only  cause  of  these  can- 
cers, but  in  these  cases  it  was  evi- 
dently the  first  embryologic  cause, 
without  which  these  carcinomas 
would  never  have  developed.  The 
same  applies  also  to  some  cases  of 
sarcoma  developing  in  a  hyperne- 
phroma which  are  in  the  collection. 
The  sarcoma  had  developed  from  the 
stroma.  Neuhauser  (Archiv  f.  klin. 
Med.,  Bd.  Ixxix,  Nu.  2,  1906). 


SYMPTOMS.— As  a  rule,  the  gen- 
eral phenomena  develop  insidiously,  the 
adrenal  lesion  being  well  advanced  when 
they  begin  to  appear.  The  strength 
wanes  more  or  less  rapidly ;  the  weight 
graually  decreases;  the  pulse  and  car- 
diac action  become  increasingly  weaker 
and  more  rapid ;  the  temperature  shows 
exacerbation  of  a  couple  of  degrees  at 
times,  but  in  the  advanced  cases  is  us- 
ually subnormal ;  the  appetite  decreases ; 
digestive  disturbances,  such  as  nausea, 
vomiting,  flatulence  and  diarrhea,  are 
commonly  observed.  Anemia  is  some- 
times manifest,  the  hemoglobin  being 
often  reduced  to  50  per  cent.,  and  the 
red  corpuscles  to  3,000,000  or  less. 
Cough,  with  bronchial  rales,  localized 
dullness  and  hemoptysis  are  occasional 
complications,  while  dyspnea  and  in- 
crease of  the  number  of  respirations  are 
apt  to  occur  in  advanced  cases.  The 
skin  may  refnain  normal,  but  various  de- 
grees of  pigmentation,  ranging  from 
slight  icterus  to  actual  bronzing,  are  ob- 
served in  the  majority  of  cases.  The 
typical  fpcies  may  alone  be  present  in 
cases  of  primary  carcinoma. 

[This  symptomatology  is  based  on  a  per- 
sonal analysis  of  60  reported  cases  of  pri- 
mary malignant  tumors  of  the  adrenals. 
The  phenomena  are  clearly  explained  by 
the  functions  I  attribute  to  the  adrenals. 
Being  the  purveyors  of  the  secretion 
which — as  the  albuminous  constituent  of 
hemoglobin— sustains  oxygenation  and 
metabolism  and,  therefore,  nutrition,  in- 
creasing emaciation,  weakness,  hypother- 
mia, the  decrease  of  hemoglobin,  etc.,  are 
but  normal  results,  all  the  other  phenom- 
ena being  secondary  thereto.  The  cases 
in  which  no  pigmentation  of  the  skin  oc- 
curs are  usually  those  in  which  but  one 
adrenal  is  involved.     C.  E.  de  M.  S.] 

Case  of  primary  sarcoma  of  the 
adrenal  glands  which  did  not  show 
symptoms  of  Addison's  disease.  The 
existence  of  the  tumor  was  not  sus- 
pected   until    after   the    death    of   the 


468 


ADRENALS,    DISEASES    OF    (SAJOUS). 


patient.  The  symptoms  present  sug- 
gested carcinoma  of  the  stomach, 
though  the  more  characteristic 
symptoms  were  absent.  Both  ad- 
renal glands  were  sarcomatous. 
Blackburn  (Amer.  Jour.  Med.  Sci., 
Aug.,  1906). 

Case  of  myxosarcoma  of  the  supra- 
renals,  in  which  the  patient  had  been 
suffering  from  gastrointestinal  dis- 
turbances, a  sense  of  weight  in  the 
abdomen  after  meals,  and  later  from 
a  pain  at  the  base  of  the  chest  on 
the  same  side.  This  pain  resembled 
that  of  muscular  rheumatism,  and 
was  especially  severe  at  night.  These 
symptoms  gradually  increased,  fol- 
lowed by  intestinal  hemorrhage,  and 
edemas  at  the  ankles.  The  urine  had 
always  been  normal,  and  there  had 
been  no  -i-^omiting.  The  tumor  could 
be  distinctly  felt  on  the  right  side, 
was  firm  in  consistence,  and  reached 
from  the  iliac  crest  to  the  costal  arch; 
the  right  lobe  of  the  liver  was  found 
pushed  upward.  The  diagnosis  of  a 
renal  tumor  was  made  and  the  opera- 
tion revealed  a  large  bilobed  growth, 
partly  softened  in  the  center,  which 
occupied  the  suprarenal  gland  and 
did  not  involve  the  kidney.  On  fur- 
ther examination  the  tumor  proved 
to  be  a  myxosarcoma.  Sicuriani  (Ri- 
forma  Medica,  Nov.  4,   1905). 

All  these  phenomena  are  seldom  wit- 
nessed in  a  single  case.  As  a  rule,  after 
a  period  of  progressive  emaciation  and 
adynamia,  a  tumor  can  be  detected  by 
palpation  posteriorly  below  the  costal 
margin,  close  to  the  vertebral  column. 
The  mass  at  first  follows  the  respira- 
tory movements  and  recedes  under 
pressure,  but  it  eventually  becomes  fixed 
and  immovable. 

In  some  cases,  especially  in  infants, 
the  tumor  cannot  be  detected  in  this 
manner,  but  the  abdomen  gradually 
enlarges  with  a  steady  increase  of 
the  line  of  dullness,  though,  perhaps, 
no  other  symptom  be  discernible.  When 
the  outline  of  the  growth  can  be  clearly 


followed  with  the  fingers,  its  border  is 
nodular,  as  in  hepatic  cancer,  but  smooth. 
Pain  is  sometimes  complained  of ;  it 
may  be  located  in  the  region  of  the  tu- 
mor ;  or,  radiating  upward  or  across  the 
back,  it  may  extend  to  the  shoulders. 

[The  pain  has  been  attributed  to  the 
"phrenic  nerve,  but  a  clearer  explanation 
is  the  effect  of  the  traction  by  the  tumor, 
upon  the  sympathetic  ganglia  and  through 
the  greater  splanchnic,  upon  the  sympa- 
thetic chain,  which  is  merged  in  with  the 
mass  of  nerves,  including  the  brachial 
plexus,  in  the  tissues  of  the  shoulders.  C. 
E.  DE  M.  S.] 

Pressure  symptoms  are  apt  to  compli- 
cate a  case  of  long  duration.  Ascites, 
general  edema,  or  edema  of  the  ankles 
or  legs  are  commonly  observed  in  such 
cases,  due  notably,  in  most  instances,  to 
pressure  upon  the  inferior  vena  cava. 
Gangrene  of  the  feet  has  also  been 
observed.  In  carcinoma  metastasis  is 
most  common  in  the  liver  and  lungs ;  in 
sarcoma  it  is  not  quite  as  frequent  and 
occurs  in  most  cases  in  the  liver  and 
kidney. 

Death  may  occur  suddenly,  preceded, 
by  very  few  of  the  above  symptoms,  es- 
pecially the  sarcomata  of  infants.  In. 
the  majority,  however,  especially  in 
adults,  the  morbid  symptoms  gradually 
develop  and  the  asthenia  increases  until 
unconsciousness,  labored  breathing  and 
coma  terminate  in  death. 

Infants  may  also  suffer  from  a  con- 
genital type  of  adrenal  tumor  which 
simultaneously  invades  the  liver.  It  is 
encountered  as  a  congenital  tumor  dur- 
ing the  first  week  of  life.  The  abdomen 
becomes  increasingly  distended ;  there  is 
moderate  emaciation,  but  no  jaundice, 
pigmentation,  ascites,  or  even  pain,  the 
child  nursing  almost  up  to  the  time  of 
death. 

Series  of  six  cases,  including  a  per- 
sonal   case,   showing  that  congenital 


ADRENALS,    DISEASES    OF    (SAJOUS). 


469 


sarcoma  of  the  adrenals  and  liver 
constitutes  a  special  type  of  malig- 
nant disease  with  its  own  peculiar 
symptoms  and  pathological  findings : 
Swelling  of  the  abdomen  occurred 
within  a  period  ranging  from  birth  to 
five  weeks,  thus  indicating  the  con- 
genital nature.  The  infants  lived  from 
one  to  sixteen  weeks,  thus  showing 
great  malignancy.  The  increase  of 
growth  could  be  discerned  from  day 
to  day,  thus  illustrating  rapid  devel- 
opment. All  were  females.  The  en- 
tire normal  liver  structure  was  prac- 
tically destroyed  in  all.  The  supra- 
renal growth  exhibited  the  peculiar- 
ity of  being  very  hemorrhagic.  No 
other  part  of  the  body  was  involved 
by  the  new  growth.  William  Pepper 
(Amer.  Jour.  Med.  Sci.,  Mar.,  1901). 

Case  of  a  female  child,  aged  7 
weeks,  who  presented  a  swelling  of 
the  belly..  On  examination  of  the  ab- 
domen the  superficial  veins  were 
found  distended,  and  the  epigastric 
and  both  hypochondriac  regions  were 
greatly  enlarged  and  prominent.  The 
surface  of  this  enlargement  was  per- 
fectly smooth  and  uniform,  presented 
no  irregularity,  and  no  pulsation  was 
visible.  Careful  palpation  revealed 
the  presence  of  a  solid  mass  which 
was  movable  during  respiration,  and 
which  was  evidently  an  enlarged  liver. 
A  second  enlargement  occupied  the 
left  half  of  the  abdomen.  It  was  also 
movable  during  respiration.  The  two 
swellings  appeared  to  be  quite  dis- 
tinct from  each  other.  The  blood 
was  frequently  examined,  and  at  first 
showed  decided  leucocytosis,  which, 
however,  disappeared.  The  patient 
steadily  lost  strength  and  emaciation 
began,  and  then  slight  edema  of  the 
lower  limbs  appeared.  The  abdomen 
became  increased  in  girth,  and  grad- 
ually the  two  areas  of  enlargement 
and  dullness  descended  into  the  right 
and  left  iliac  fossa  respectively.  A 
provisional  diagnosis  of  splenic  ane- 
mia with  coincident  hepatic  enlarge- 
ment was  made.  The  post-mortem 
examination  revealed  the  fact  that 
the  enlargement  of  the  liver  was  due 
to  the  presence   of  numerous   sarco- 


matous nodules.  The  primary  growth 
was  discovered  in  the  right  adrenal. 
John  Orr  (Edinburgh  Med.  Jour., 
Sept.,  1900). 

Case  of  primary  malignant  tumor 
of  the  adrenal  occurring  in  a  child 
2  months  old.  The  parents  first  no- 
ticed a  slight  swelling  of  the  abdo- 
men, which  increased  rapidly.  On 
examination  the  writer  found  distinct 
enlargement,  some  edema  of  the 
abdominal  walls,  and  the  superficial 
veins  much  distended.  On  palpation 
a  hard,  smooth  mass  was  felt,  chiefly 
in  the  right  side  of  the  abdomen,  ex- 
tending from  the  costal  margin  down 
to  the  right  inguinal  region,  passing 
deeply  into  the  right  flank  and  filling 
up  the  whole  space  between  the  ribs 
and  the  iliac  crest.  In  the  right  in- 
guinal region  a  firm  edge  was  felt, 
which  could  be  traced  from  Poupart's 
ligament  toward  the  navel,  passing 
below  the  navel  and  then  gradually 
ascending.  To  the  left  of  the  navel 
a  notch  could  indistinctly  be  felt,  but 
it  was  not  possible  to  distinguish  two 
separate  masses.  The  length  of  the 
tumor  mass  in  the  median  line  was 
16  cm.,  the  distance  from  the  inter- 
clavicular notch  to  the  umbilicus  was 
21.5  cm.,  and  the  greatest  circumfer- 
ence of  the  abdomen  was  46  cm.  The 
uniform  tumor  apparently  repre- 
sented the  liver.  The  red  blood-cor- 
puscles numbered  2,800,000;  the  white 
11,000,  of  which  79  per  cent,  were 
polymorphonuclears,  18.5  per  cent, 
small  mononuclears,  2.3  per  cent, 
large  mononuclears  and  transitionals, 
and  0.2  per  cent,  eosinophiles.  The 
child  died  in  convulsions  six  days 
after  it  was  seen  the  first  time.  The 
autopsy  disclosed  a  tumor  of  the  left 
adrenal  gland  and  a  very  much  en- 
larged liver.  The  liver  was  cirrhotic 
and  fatty,  and  contained  numerous 
masses  of  cells,  the  same  as  those  in 
the  adrenal  tumor.  Amberg  (Arch- 
ives of  Pediatrics,  Aug.,  1904). 

DIAGNOSIS.— The  diagnosis  of 
malignant  tumor  is  not  difficult  when 
the  tumor  is  sufficiently  large  to  be  dis- 
covered by  palpation,  especially  when 


470 


ADRENALS,    DISEASES    OF    (SAJOUS). 


paresthesia  over  the  kidney  is  present. 
This  and  the  asthenic  phenomena  point 
clearly  to  the  adrenals,  especially  if 
jaundice  or  any  pigmentation  of  the  skin 
be  present.  Unfortunately,  the  morbid 
process  is  far  advanced,  as  a  rule,  when 
these  signs  appear.  The  tumor  has  been 
mistaken  for  psoitis  and  abscess.  From 
hepatic  cancer  it  differs  in  that  the  sur- 
face of  the  tumor  is  smooth  instead  of 
lobulated.  Of  course,  the  possibility  of 
metastasis  in  the  liver,  its  most  frequent 
seat,  must  be  borne  in  mind.  Hydatid 
cyst  may  be  suggested,  but  the  absence 
of  the  hydatid  thrill  and  other  typical 
symptoms  will  avoid  error.  A  project- 
ing and  enlarged  gall-bladder  is  some- 
times simulated  by  an  adrenal  tumor 
capable  of  displacing  the  intestines  an- 
teriorly; but  the  latter  are  much  less 
tense  than  such  a  gall-bladder.  Ab- 
dominal aneurism  may  be  suggested,but 
the  absence  of  aneurismal  bruit  and  the 
absence  of  all  other  signs  of  adrenal 
growth  eliminate  this  source  of  error. 
In  renal  cancer  or  renal  hypernephroma 
hematuria  and  other  evidences  of  renal 
disorder  are  usually  present,  while  they 
are  more  likely  to  be  absent  in  malig- 
nant growths  of  the  adrenals.  Pain  oc- 
curs earHer  than  in  renal  tumors,  while 
febrile  disturbance  is  rare  in  the  latter. 

Two  symptoms  point  to  involve- 
ment of  the  suprarenal  gland:  (a) 
paroxysms  of  pain  and  paresthesias 
in  the  absence  of  a  palpable  tumor, 
and  (b)  a  febrile  course.  The  pain- 
ful paroxysms  in  renal  as  well  as 
suprarenal  tumors  are  due  to  the  ex- 
tension of  the  neoplasm  to  the  roots 
of  the  lumbar  plexus.  In  suprarenal 
tumor  this  may  occur  quite  early, 
owing  to  the  immediate  vicinity  of 
these  structures.  On  the  other  hand, 
in  renal  tumors  the  invasion  of  the 
capsule  usually  takes  place  at  a  late 
period,  when  the  growth  has  reached 
so  considerable  a  size  as  to  become 


palpable.  The  fact  that  fever  occurs 
in  cases  of  suprarenal  tumors  has 
hitherto  been  unknown.  The  writer 
observed  it  in  57  per  cent,  of  his 
cases,  while  in  renal  tumors  it  was 
present  only  in  1  to  2  per  cent. 

Another    apparently     characteristic 
fact  in  differentiating  from  renal  tu- 
mor is  that  the  adrenal  growth  tends 
to  approach  more  nearly  the  median 
line — in  the  region  from  the  seventh 
to  the  ninth  costal  cartilages;  while 
the  primary  tumor  of  the  kidney  ap- 
pears   first    in    the    region    from    the 
ninth  to  the  eleventh.     Tumor  of  the 
adrenal  at  the  time  of  its  presenta- 
tion beneath  the  margin  of  the  ribs 
appears    broader    than    does    that    of 
tumor  of  the  kidney,  and  the  lower 
contour  of  the  tumor  of  the  adrenal 
is  much  less  rounded  than  is  that  of 
the    kidney.      J.    Israel    (Deut.    med. 
Woch.,   Nu.  44,   1905). 
[The    emphasis     laid    by    Israel   on   the 
presence    of   fever    in    adrenal    malignant 
neoplasms    affords    striking    proof    of    the 
correctness  of  my  contention  that  the  ad- 
renals, through  the  role  of  its  secretion  in 
oxidation  and  metabolism,  was  the  active 
organ  in  fever — a  process  which  patholo- 
gists have  totally  failed  to  explain.     C.  E. 
deM.  S.] 

Lencocythemia  is  sometimes  simu- 
lated, but  the  absence  of  myelocytes  and 
other  characteristics  soon  eliminate  this 
disease. 

Ecchymosis  of  the  orbit  of  unaccount- 
able origin  in  infants  and  young  chil- 
dren, or  tumor  of  the  orbit  should  cause 
careful  search  for  other  manifestations 
of  malignant  hypernephroma  of  the  ad- 
renals. 

TREATMENT.— Removal  is  the 
only  resource,  but,  as  a  rule,  the  result 
is  unsatisfactory,  owing  to  the  fact  that 
the  presence  of  the  growth  is  recognized 
only  through  metastasis ;  or  when  it  has 
developed  to  a  marked  extent,  and  pro- 
duced either  through  metastasis,  press- 
ure, etc.,  disorders  in  other  parts  of  the 
organism  which  cannot  be  reached. 


ADRENALS,    DISEASES    OF    (SAJOUS). 


471 


Three  cases  of  adrenal  tumor 
treated  by  removal.  One  was  in  a 
woman,  aged  47,  on  whom  the  writer 
operated  in  1891,  who  died  of  recur- 
rence of  sarcoma  and  exhaustion  sev- 
eral months  after  the  operation.  The 
suprarenal  growth  was  so  firmly 
fixed  to  the  top  of  the  kidney  that 
that  organ  had  to  be  removed  as 
well.  The  second  case  was  that  of  a 
woman,  aged  62,  on  whom  he  op- 
erated in  1897,  and  who  is  still  living 
and  well,  the  tumor  removed  having 
been  a  struma  lipomatosa  suprare- 
nalis,  as  described  by  Virchow.  In 
this  case  only  a  wedge-shaped  piece 
from  the  top  of  the  kidney  was  re- 
moved with  the  tumor,  a  procedure 
followed  by  no  morbid  symptom. 
The  third  operation,  by  his  colleague, 
Mr.  Ward,  was  for  a  sarcoma  of  the 
adrenal  in  a  child,  aged  12  months. 
The  child  died  from  shock  within  a 
few  hours. 

Of  9  cases,  including  his  own,  5 
recovered  from  the  operation  and  4 
died.  The  true  secret  of  success  lies 
in  operating  at  an  early  stage  of  the 
growth,  as  in  the  writer's  second 
case.  Mayo  Robson  (Med.  Press  and 
Circular,  Aug.  23,  1899). 

Removal  of  an  adrenal  myxosar- 
coma from  a  man  of  SO.  The  tumor 
weighed  about  seven  pounds  when 
removed.  There  was  no  cachexia, 
mononuclear  leucocytosis  or  other 
symptoms  pointing  to  the  suprarenals. 
The  sound  suprarenal  must  have 
acted  vicariously  for  the  affected  or- 
gan. The  patient  had  recovered  when 
last  seen,  two  months  after  a  two- 
hour  operation.  F.  Sicuriani  (Riforma 
Medica,  vol.  xxi,  No.  44,  1905). 

Cases  in  which  the  tumor  involves 
one  adrenal  only,  as  suggested  by  the 
absence  of  symptoms  of  adrenal  insuffi- 
ciency, marked  asthenia^emaciation,  hy- 
pothermia, etc.,  and  the  presence  of  a 
tumor  and  hyperesthesia  on  one  side 
only,  ofifer  a  better  chance  of  success, 
since  they  indicate  that  the  other  ad- 
renal will  probably  be  able  to  subserve 
alone  the  needs  of  the  organism.     The 


chief  difficulties  encountered  in  the 
course  of  the  operation  are  a  marked 
tendency  to  hemorrhage,  owing  to  the 
friability  of  the  morbid  tissues. 

HYPERNEPHROMA.— This 
name  has  been  given  to  tumors  formerly 
considered  as  lipomata,  adenomata  or 
myxomata,  but  shown  by  Grawitz  in 
1883  to  be  developed  from  adrenal  tis- 
sue, either  within  the  adrenals  them- 
selves or  in  the  kidneys,  the  walls  of 
blood-vessels  or  other  structures  in 
which  "adrenal  rests"  (fragments  of 
misplaced  adrenal  tissue)  or  "aberrant 
adrenals"  occur. 

From  my  viewpoint,  these  so-called 
"adrenal  rests" — found  in  90  per  cent, 
of  all  autopsies  by  Bayard  Holmes,  at 
least  once  a  week  by  Grawitz  in  his  au- 
topsies, etc. — are  not  misplaced  frag- 
ments of  adrenal  tissue;  they  belong 
normally  to  the  kidney. 

[I  have  shown  (Monthly  Cyclo.,  June 
and  July,  1909)  that  what  has  been  termed 
the  internal  secretion  of  the  kidney  is  a 
product  the  properties  of  which  correspond 
with  those  of  the  adrenals,  and  (see  "In- 
ternal Secretions,"  3d  ed.,  p.  289,  1908)  that 
the  kidney  and  the  adrenals  were  governed 
by  the  same  nervous  structures,  being  thus 
closely  linked  functionally.  Under  the  in- 
fluence of  centric  impulses  the  sorcalled 
adrtnal  rests  and  t'le  adrenals  are  both 
caused  to  increase  their  secretory  activit}'- 
and  to  enhance  the  intrinsic  metabolism  of 
the  tissues  they  supply.  On  the  whole  the 
"adrenal  rests"  are  but  local  aggregates  of 
the  chromaffin  substance  found  in  all  sym- 
pathetic structures.    C.  E.  de  M.  S.] 

Study  based  upon  48  hypernephro- 
mata.  Thirty-four  of  the  tumors  were 
removed  at  operations  in  the  Mayo 
Clinic,  and  14  were  unreported  cases 
gathered  from  outside  sources.  The 
following  general  conclusions  are  drawn 
from  this  study:  1.  Most,  if  not  all, 
so-called  "adrenal  rests"  are  probably 
of  Wolffian  origin.  2.  There  is  almost 
no  evidence,  embryological  or  histolog- 
ical, in  support  of  Grawitz's  hypothesis 


472 


ADRENALS,    DISEASES    OF    (SAJOUS). 


that  the  so-called  hypernephromata  have 
their  origin  in  adrenal  rests.  3.  There 
is  much  evidence  that  the  so-called 
hypernephromata  do  arise  (according 
to  Stoerk's  hypothesis)  from  prolifera- 
tions of  the  adult  secreting  epithelium 
of  the  convoluted  tubules.  4.  There  is 
much  evidence  that  the  so-called  hyper- 
nephromata do  arise  from  islands  of 
nephrogenic  tissue  (primitive  renal 
blastema).  Such  tissue  is  sometimes 
present  in  the  adult  kidney  and  appears 
capable  of  forming  tumors  of  non-infil- 
trating mixed  .cordon,  tubular,  papilli- 
form,  and  sarcoma  type  characteristic 
of  the  so-called  hypernephromata.  L. 
B.  Wilson  (Jour,  of  Med.  Research, 
Jan.,  1911). 

Hypernephromas  are  relatively  com- 
mon in  the  kidney,  constituting,  as 
shown  by  Albarran  and  Joubert,  17  per 
cent,  of  all  renal  tumors ;  they  are  much 
less  frequently  found  in  the  adrenals 
proper,  or  in  other  organs,  such  as  the 
uterus,  ovary,  the  broad  ligament.  Mi- 
croscopically they  present  the  typical 
characters  of  the  adrenal  cortex,  and 
closely,  as  a  rule,  infest  vascular  chan- 
nels. These  vessels  and  adjacent  tissues 
usually  contain  a  colloid  material  simi- 
lar to  that  found  in  the  thyroid,  or  se- 
creted by  the  adrenals.  They  are  be- 
nign at  first  and  become  troublesome — 
sometimes  after  many  years — mainly  on 
account  of  their  size,  which  sometimes 
reaches  that  of  a  child's  head,  but  the 
pressure  they  exert  on  surrounding 
structures,  their  tendency,  even  when 
benign,  to  metastasize  in  the  lungs, 
bones,  brain,  give  them  their  malig- 
nancy. 

Case  of  hypernephroma  encroaching 
upon  the  heart.  The  earlier  symptoms 
were  cardiac  with  great  weakness, 
one  and  one-half  years  before  urinary 
phenomena  occurred.  Then  followed 
hematuria,  and  a  tumor  was  discovered 
in  the  left  kidney ;  it  proved  on  removal 
to  be  a  hypernephroma  from  an  aber- 
rant suprarenal  tissue  proliferating  into 


the  ascending  vena  cava  with  a  tumor 
thrombus  up  in  the  right  auricle.  Skip- 
■ping  the  right  ventricle,  it  had  prolifer- 
ated into  the  pulmonary  artery.  Kirsch- 
ner  (Berl.  klin.  Woch.,  Sept.  25,  1911). 

SYMPTOMATOLOGY.— Before 

the  local  symptoms  of  the  tumor  appear 
— when  any  are  clearly  discernible — it 
evokes  phenomena  which  are  diametri- 
cally opposed  to  those  of  Addison's  dis- 
ease, and  which  correspond  with  in- 
creased nutrition  and  a  stimulation  of 
growth  such  as  that  produced  by  thy- 
roid preparations  in  cretinism. 

[This  action  on  growth  and  its  resem- 
blance to  that  brought  about  by  thyroid 
overactivity  has  imposed  itself  upon  in- 
vestigators quite  independently  of  my  own 
view — advanced  in  1903  ("Internal  Secre- 
tions," vol.  i,  pp.  146-152),  that  it  was  in 
great  part  through  the  adrenals,  i.e., 
through  incidental  stimulation  of  the  ad- 
renal center  by  the  thyroid  secretion,  that 
the  benefit  of  thyroid  in  cretinism  was 
produced.  The  confirmatory  evidence  it 
affords  is  self-evident.  The  excess  of  ad- 
renal tissue  which  constitutes  hyperneph- 
roma brings  about  the  general  phenomena 
of  overnutrition  merely  because  it  awak- 
ens excessive  metabolism  precisely  as  if 
the  thyroid  overactivity  had  done  so  by 
exciting  the  adrenal  center.  C.  E.  de  M. 
S.] 

The  symptomatology  varies  consider- 
ably in  different  cases  and  suggests  that 
several  types  exist  which  our  present 
knowledge  does  not  enable  us  to  dis- 
criminate. Some  of  these  exhibit  such 
malignancy  that  they  have  been  grouped 
in  a  separate  class.  Beginning  with  hy- 
pernephromas of  the  adrenals  proper, 
we  will  first  review  this  class  of  cases. 

MALIGNANT  HYPERNEPH- 
ROMA OF  THE  ADRENALS.— 
This  growth  occurs,  as  a  rule,  between 
the  first  and  eighth  year,  especially  in 
girls  of  the  latter  age,  and  causes  pre- 
mature development  so  marked,  in  some 
instances,  that  the  child  appears,  as  to 


s''--  - 


Appearances  of  kidney  and  tumor  on  section  through  the  long  axis  of  the  organ  and 
its  pelvis.     (Annals  of  Surgery,  Dec.  1906.) 


Hypernephroma.     Showing  the  external  appearance  of  the  kidney  and  tumor  about 
one-third  smaller  than  at  the  time  of  operation.     (Annals  of  Surgery,  Dec,  1906.) 


ADRENy\LS,    DISEASES    OF    (SAJOUS). 


473 


size  and  development,  twice  or  three 
times  its  true  age.  The  face,  genitaha, 
and  pnhis  are  covered  with  abundant 
growth  of  hair,  the  external  genitalia 
being  as  fully  developed  as  in  the  adult. 
The  body  is  obese,  the  appetite  and 
thirst  excessive,  although  gastric  dis- 
orders, including  stubborn  vomiting,  are 
common.  The  skin  may  be  swarthy  or 
dark-hued,  as  in  a  brunette,  but  not 
bronzed  as  in  Addison's  disease.  Such 
children  are  usually  cross  and  sullen, 
unlike  obese  children,  in  whom  the  obes- 
ity is  due  to  deficient  fat  catabolism. 
These  primary  growths  of  the  adrenals, 
which  are  usually  observed  in  girls,  are 
of  slow  development,  and  years  usually 
elapse  before  metastasis  and  press- 
ure phenomena — those  which  give  the 
growth  its  malignancy — appear. 

The  abnormal  growth  of  the  child 
may  suggest  gigantism  or  acromegaly, 
due  to  some  disorder  of  the  pituitary 
body,  but  the  characteristic  growth  of 
the  extremities,  the  absence  of  obesity 
in  these  disorders  do  not  occur  in  hyper- 
nephroma. An  elevated  temperature  is 
often  observed  in  these  cases. 

Removal  of  14  cases  of  malignant 
hypernephroma.  Fever  was  a  promi- 
nent symptom,  unaccounted  for  by  any 
complication.  This  reaction  may  be 
early,  intercurrent,  or  late.  It  some- 
times is  the  first  clinical  evidence  of 
the  malady,  or  it  may  accompany  the 
evolution  of  the  disease;  or  it  may  be 
a  terminal  symptom.  The  type  may 
be  hectic,  recurrent,  or  one  associated 
with  hematuiia;  or  the  fever  .may  be 
atypical.  The  reaction  cannot  be  con- 
nected with  liberation  of  bacterial 
toxins  or  absorption  from  necrobi- 
otic  tissues.  It  doubtless  accompan- 
ied the  evolution  of  all  malignant 
growths,  but  the  rationale  is  not  clear. 
Israel  (Deut.  med.  Woch.,  Jan.  12, 
1911). 
[The  occurrence  of  fever  in  these  cases 
is  clearly  accounted  for  by  my  views.     As 


shown  in  "Internal  Secretions"  (vol.  ii,  p. 
1907),  the  pituitary  body  contains  the  sym- 
pathetic center  besides  the  adrenal  center. 
During  the  first  or  erethic  stage,  therefore, 
the  adrenals,  the  secretion  of  which  sus- 
tains oxidation  and  metabolism,  and  which 
alone  cause  overgrowth  in  malignant  hy- 
pernephroma, are  not  alone  overactive,  but 
the  arterioles,  which  the  sympathetic  gov- 
erns, also.  The  blood  is  not  only  abnor- 
mally rich  in  oxygenizing  properties,  there- 
fore, in  this  disease  as  it  is  in  malignant 
hypernephroma,  but  it  is  also  driven  with 
excessive  energy  into  the  tissues,  particu- 
larly in  the  long  capillary  loops  of  the  ex- 
tremities. Hence  the  difference  between 
the  phenomena  of  overgrowth  in  the  two 
diseases  and  the  elevated  temperature. 
C.  E.  DE  M.  S.] 

Turhor  of  the  orbit  in  infants  and 
young  children  should  arouse  the  sus- 
picion of  metastases  from  an  adrenal 
growth.  If  an  abdominal  tumor  be 
found,  it  is  almost  certainly  of  ad- 
renal origin,  and  this  would  be  still 
further  corroborated  by  enlargement 
of  the  preauricular  glands,  which  ren- 
ders the  diagnosis  of  sarcoma  of  the 
orbit  unlikely.  Chloroma  presents 
almost  identical  growths,  being  as- 
sociated with  tumors  of  the  orbit  in 
two-thirds  of  the  cases,  with  exoph- 
thalmos usually  as  the  first  symptom, 
but  this  may  be  excluded  in  the  ab- 
sence of  leukemic  changes  in  the 
blood.  Myeloma  may  cause  bony 
growths  about  the  skull,  but  is  ex- 
ceedingly rare  in  childhood;  the  pres- 
ence of  the  Bence-Jones  body  in  the 
urine  would  render  the  diagnosis  of 
myeloma  certain,  while  its  absence 
is  not  conclusive.  The  authors  state 
that  abdominal  tumor  associated  with 
precocious  maturity  is  practically 
certain  to  be  of  adrenal  origin,  if  tu- 
mors of  the  ovaries  or  a  retained  tes- 
tis can  be  excluded.  Other  adrenal 
tumors  cannot  be  distinguished  from 
tumors  of  the  adjacent  tissues,  es- 
pecially of  the  kidneys.  Tileston  and 
Walbach'  (Amer.  Jour.  Med.  Sci., 
June,  1908). 

Case  of  tumor  of  the  adrenal  gland 
with  metastasis  in  and  about  the 
orbit.     The  following   are   the   char- 


474 


ADRENALS,    DISEASES    OF    (SAJOUS). 


acteristic  symptoms  usually  found  in 
infants  or  young  children:  Ecchy- 
mosis  of  the  eyelids,  accompanied  by 
exophthalmos,  suddenly  appears;  it 
may  be  followed  by  growths  about 
the  orbit.  It  is  usually  confined  to 
one  side.  The  glands  throughout  the 
body  are  apt  to  be  enlarged.  Exam- 
ination of  the  abdomen  may  reveal 
a  tumor  in  the  region  of  the  kidney, 
or  a  mass  may  be  felt  in  other  parts 
of  the  abdomen.  The  blood  shows 
secondary  anemia.  The  urine  is  usu- 
ually  free  from  blood  and  albumin. 
Most  of  the  reported  cases  have  been 
under  4  years  of  age.  The  course 
of  the  disease  is  rapid,  death  result- 
ing from  cachexia  and  anemia. 

The  author  also  calls  attention  to 
the  following:  1.  Tumors  of  the  or- 
bit in  young  children,  especially  if 
accompanied  with  ecchymosis  of  the 
lid,  should  arouse  suspicion  of  metas- 
tasis from  an  adrenal  growth.  2.  The 
microscopic  examination  of  speci- 
mens shows  a  characteristic  rosette 
formation  of  cells.  3.  This  form  of 
tumor  arises  from  embryonic  nerve- 
cells  of  the  adrenal  gland.  Quacken- 
bos  (Arch.  Ophthal.,  Sept.,  1910). 

Case  of  malignant  hypernephroma 
in  a  boy  of  9  years,  who  had  always 
been  pale  and  weak.  Six  weeks  after 
an  acute  pericarditis  the  symptoms  of 
the  malignant  disease  became  ap- 
parent and  the  tumor  soon  penetrated 
into  the  thorax.  Three  other  cases 
are  on  record  in  which  a  malignant 
hypernephroma  developed  in  a  child. 
The  other  children  were  between  2 
and  5  years  old;  in  one  the  tumor 
had  developed  on  a  horseshoe  kidney. 
All  were  distinguished  by  extreme 
malignancy,  but  no  hematuria  was 
observed.  In  the  222  cases  of  hyper- 
nephroma the  writer  has  found  on 
record  a  traumatic  factor  was  evident 
in  only  eight  instances.  Franck 
(Beitrage  z.  klin.  Chir.,  Jan.,  1910). 

Infants  and  young  children  are  also 
subject  to  a  form  of  primary  malignant 
tumor  of  the  adrenals,  described  by 
Hutchinson,  in  which,  even  before  the 
neoplasm^  which  grows  with  great  ra- 


pidity, can  be  felt  in  the  renal  region, 
there  appears  a  spontaneous — some- 
times traumatic — ecchymosis  of  one  or 
both  eyelids,  soon  followed  by  (usually 
unilateral)  exophthalmos  and  metasta- 
sis in  the  skull,  and  often  in  other  bones, 
especially  the  ribs.  The  preauricular 
lymph-nodes,  and  those  behind  the  angle 
of  the  jaw,  are  enlarged,  and  the  whole 
temporal  region  eventually  becomes  the 
seat  of  a  malignant  growth.  Pain  in 
this  location  and  optic  neuritis  with 
amblyopia  may  complicate  the  case. 
Death  occurs  early  from  anemia  and 
cachexia. 

Out  of  196  cases  of  kidney  tumor 
146  were  hypernephromata — that  is, 
almost  exactly  75  per  cent.  The  re- 
maining 25  per  cent,  are  made  up 
mostly  of  sarcomata,  to  a  much  less 
extent  of  squamous  epitheliomata  of 
the  pelvis,  while  a  true  carcinoma  of 
the  kidney,  apart  from  hyperne- 
phroma, is  a  very  great  rarity,  or, 
possibly,  does  not  exist.  The  kidney 
tumors  of  children  are  practically  all 
sarcomata;  there  is  but  one  case  on 
record  of  a  true  hypernephroma  in  an 
infant,  and,  as  was  long  ago  pointed 
out  by  Kiister,  malignant  disease  of 
the  kidney  is  a  disease  of  earliest 
childhood  and  middle  age,  affecting 
but  little  young  adults  and  the  aged. 
Hence,  we  may  lay  it  down  definitely 
that  hypernephroma  is  the  common 
kidney  tumor  of  adults,  and,  con- 
versely, that  any  given  kidney  tumor 
in  an  adult  is  much  more  likely  to  be 
one  of  this  type  than  anything  else. 
This  is  the  only  etiological  fact  bear- 
ing on  the  disease  which  we  can  re- 
gard as  absolutely  definite.  Trotter 
(Lancet,  June  5,   1909). 

Adrenal  carcinoma  shows  two  en- 
tirely distinct  syndromes  and  path- 
ological states,  according  to  which  adre- 
nal is  the  seat  of  the  primary  tumor. 
On  the  left  side  secondary  deposits 
occur  in  the  liver,  ribs,  cranial  bones, 
and  in  the  thoracic  duct  and  some  of  its 
tributaries.  On  the  right  side  the  pri- 
mary growth  generally  attains  a  larger 


ADRENALS,    DISEASES    OF    (SAJOUS). 


475 


size,  and  oftener  remains  localized  to 
the  abdomen.  It  tends  to  involve  the 
kidneys  by  direct  extension  into  their 
pelves,  stretching  out  the  kidney  sub- 
stance over  it,  but,  as  a  rule,  being  easily 
separated.  Secondary  deposits  occur  on 
the  upper  surface  of  the  liver,  in  both 
lungs,  occasionally  in  the  cranial  bones, 
and  also  in  the  right  lymphatic  duct 
and  some  of  its  branches.  The  lym- 
phatics of  the  right  suprarenal  are  trib- 
utaries of  the  right  lymphatic  duct,  and 
do  not,  as  is  usually  stated,  follow  a 
course  similar  to  that  of  the  lymphatics 
of  the  left  adrenal,  viz.,  join  the  lumbar 
glands.  Deposits  in  the  cranial  bones 
often  cause  exophthalmos,  this  usually 
occurring  first  on  the  same  side  as  the 
primary  growth.  Ecchymoses  into  the 
eyelids  may  occur  and  lead  to  confusion 
of  the  disease  with  chloroma  and  in- 
fantile scurvy.  The  tumor  in  these 
cases  involves  the  medulla  of  the  adre- 
nal, and  there  are  reasons  for  believing 
that  it  is  of  carcinomatous  nature.  No 
pigmentation  or  evidence  of  a  prema- 
ture sexual  development,  such  as  have 
been  described  as  occurring  in  cases 
of  carcinoma  of  the  cortex  of  the  supra- 
renal, were  found  in  any  of  the  cases 
studied.  R.  S.  Frew.  (Quarterly  Jour, 
of  Med.,  Jan.,  1911). 

HYPERNEPHROMA  OF  THE 
KIDNEY. — It  is  to  renal  growths  de- 
veloped from  the  so-called  "adrenal 
rests"  that  Grawitz,  in  1883,  gave  the 
name  "hypernephroma."  They  occur 
not  only  more  frequently  in  the  kidnevs 
than  elsewhere  in  the  body,  but  consti- 
tute a  large  proportion  of  all  renal  tu- 
mors, i.e.,  17  per  cent. 

S  Y  M  P  T  OMATOLOGY.— Hema- 
turia is  often  the  first  and  the  most  fre- 
quently observed  symptom  of  renal  hy- 
pernephroma, having  been  noted  in  90 
per  cent,  of  all  cases.  The  hemorrhages 
are  usually  severe  and  occur  intermit- 
tently, weeks  and  even  months  elapsing 
between  them.  Worm-like  clots — thus 
shaped  during  their  passage  through  the 
ureters — are  often  passed.     During  the 


intervals  the  urine  is  either  clear  or  it 
may  contain  red  corpuscles.  The  hema- 
turia is  increased  by  exercise  and  by 
manipulation  of  the  region  overlying 
the  growths  if  the  latter  is  sufficiently 
large  to  be  felt.  It  may  be  the  only 
symptom  of  the  growth  or  precede  the 
detection  of  the  latter  by  palpation  as 
much  as  ten  years.  As  a  rule,  however, 
the  tumor  (which  occurs  in  80  per  cent, 
of  all  cases)  is  sufficiently  large  to  be 
detected  inuch  earlier,  and  som.etimes 
immediately  after  an  attack  of  hema- 
turia. It  is  located  in  the  loin,  often  on 
the  right  side,  and  two  or  three  fmger- 
breadths  below  the  costal  margin.  It  is 
at  first  small — about  the  half  of  a  wal- 
nut— and  is  movable  in  about  one-half 
of  the  cases.  As  a  rule,  palpation  cattses 
no  pain  at  first,  though  it  may  prove  ten- 
der when  directly  pressed  upon. 

Dull  pain  in  the  lumbar  region,  sug- 
gesting lumbago,  may  be  the  initial 
symptom.  This  pain  gradually  increases 
and,  after  being  centered  in  the  region 
of  the  growth,  with  a  sensation  of 
weight,  increasingly  radiates  in  various 
directions,  the  back,  the  abdomen  and 
the  testicles.  It  may  come  on  suddenly 
and  last  three  or  four  hours,  then  be 
followed  by  hematuria  and  frequent 
urination,  followed  by  a  period  of  rest, 
during  which  the  urine  is  slightly  albu- 
minous. The  urine  sometimes  contains 
a  few  casts,  oxalate  of  lime  and  a  few 
corpuscles.  During  this  period  of  rest 
a  certain  stiffness  may  be  experienced 
en  the  side  of  the  tumor.  Varicocele  is 
frequently  observed  in  these  cases,  on 
the  same  side  as  the  focus  of  pain ;  it 
may  develop  simultaneously  with  the 
latter  and  disappear  when  the  patient 
assumes  the  recumbent  position. 

While  periodical  hematuria,  a  tumor 
and  pain  in  the  locations  mentioned  are 
typical  signs  of  renal  hypernephroma, 


476 


ADRENALS,    DISEASES    OF    (SAJOUS). 


other  phenomena  may  appear  gradually 
as  the  morbid  process  advances.  Most 
important  among  these  are  the  metasta- 
ses, which  occasionally  occur  as  first 
signs  of  the  disease.  This  is  especially 
the  case  in  bone  metastasis,  which  may 
appear  in  the  vertebrae,  the  ribs  and 
other  long  bones,  the  skull,  scapula,  etc., 
i.e.,  practically  any  portion  of  the  skele- 
ton. Metastasis  may  also  occur  in  va- 
rious viscera,  particularly  the  lungs,  the 
consolidation  in  the  latter  suggesting 
the  corresponding  stage  of  phthisis. 

Case  in  which  the  symptoms  and 
the  local  findings  were  so  obscure 
that  it  was  impossible  to  make  a  cor- 
rect diagnosis.  The  abdomen  was 
opened  on  the  left  border  of  the  left 
rectus  muscle.  The  capsule  of  the 
tumor  was  carefully  incised  and  the 
peritoneum  thus  liberated  was  sewed 
to  the  parietal  peritoneum  of  the  lapa- 
rotomy wound,  thus  shutting  off  com- 
pletely the  peritoneal  cavity  from  the 
field  of  operation.  The  tumor  and 
the  kidney,  to  which  it  was  attached, 
were  delivered  through  the  incision 
and  the  tumor  carefully  enucleated. 
No  large  blood-vessels  were  severed, 
but  the  oozing  from  the  cut  surface 
of  the  cortex  of  the  kidney  could  only 
be  arrested  by  bringing  the  capsule 
on  one  side  against  the  capsule  on 
the  other  by  three  mattress  stitches. 
The  kidney  was  allowed  to  fall  back 
into  its  normal  position.  With  the 
exception  of  the  development  of  a 
periappendicular  abscess  in  an  old  ap- 
pendicitis scar,  the  patient  made  an 
uneventful  and  rapid  recovery.  A 
microscopic  examination  of  the  tumor 
showed  that  it  was  a  typical  adrenal 
growth.  Bayard  Holmes  (Med.  Stand- 
ard, Nov.,   1904). 

Series  of  27  cases  in  which  a  single 
bone  metastasis  was  the  first  symp- 
tom of  the  disease.  Two  were  au- 
topsy cases.  In  one  case  the  metas- 
tasis to  the  scapula  was  excised,  and 
•  the  patient  has  remained  well  so  far, 
eighteen  months  after  operation.  In 
another  instance  the  metastatic  area 


in  the  occipital  bone  showed  ossifica- 
tion. This  so-called  osteoplastic  car- 
cinosis has  been  described  by  von 
Recklinghausen  in  metastatic  bone 
foci  from  carcinoma.  Albrecht  (Zen- 
tralbl.  f.  Chir.,  Bd.  xxxii,  S.  112, 
1905). 

Case  of  renal  hypernephroma  in 
which  the  first  evidence  was  a  metas- 
tasis in  the  upper  part  of  the  hu- 
merus, the  only  sign  of  the  primary 
growth  being  an  enlargement  of  the 
left  kidney.  Fifteen  cases  from  liter- 
ature suggested  the  following  deduc- 
tions in  this  connection:  1.  A  bone 
metastasis  may  be  the  first  sign  of 
hypernephroma.  2.  A  bone  tumor  in 
a  middle-aged  or  elderly  person 
should  suggest  a  metastatic  hyper- 
nephroma, for  a  primary  bone  tumor 
in  elderly  people  is  uncommon.  3. 
The  bone  metastasis  from  a  hyper- 
nephroma may  be  the  only  metasta- 
sis. 4.  A  hypernephroma  may  exist 
for  a  considerable  period  without 
symptoms.  5.  The  kidney  region 
should  be  palpated  with  great  care 
in  every  case  of  bone  tumor.  C.  L. 
Scudder  (Annals  of  Surg.,  Dec, 
1906). 

The  arteries  may  be  thickened  and 
show  clearly  defined  signs  of  arterio- 
sclerosis, quite  in  contrast,  sometimes, 
with  the  relative  youth  of  the  patient, 
and  the  blood-pressure  be  quite  high. 
The  skin  is.  not  bronzed  in  these  cases, 
but  yellowish,  and  sometimes  swarthy 
or  smoky,  this  being  replaced  by  pallor 
when  the  end  is  near.  The  temperature 
may  be  raised,  but  this  rarely  exceeds 
1°  or  2°  F. 

[An  important  feature  in  this  connec- 
tion is  that  bronzing  is  a  characteristic  of 
insufficiency  of  the  adrenals,  as  in  Addison's 
disease,  whether  due  to  degeneration,  tu- 
berculosis, or  malignant  tumor  of  these 
organs  or  of  their  nerve  supply.  In  hyper- 
nephroma, on  the  contrary,  we  have  an 
addition  of  adrenal  substance  to  the  cir- 
culation through  the  secretory  activity  of 
the  adrenal  rests,  as  shown  by  the  familiar 
results  of  adrenal  overactivity  enumerated 


ADRENALS,    DISEASES    OF    (SAJOUS). 


477 


— liigli  blood-prcssurc  and  arteriosclerosis. 
The  icterus  or  swarthiness  here  is  due, 
from  my  viewpoint,  to  the  continuously 
high  blood-pressure  which  causes  the  cu- 
taneous capillaries  to  become  hj^peremic 
and  to  expose  an  increased  quantity  of 
the  adrenal  principle — the  component  of 
melanin  (see  "Internal  Secretions,"  vol.  ii, 
p.  835)  to  oxidation.  The  stage  of  bronz- 
ing is  not  reached  because  the  pigment  is 
not  deposited  in  the  cutaneous  tissues,  as 
it  is  in  Addison's  disease,  but  merely  sup- 
plied to  them  in  excess.     C.  E.  de  M.  S.] 

The  duration  of  the  disease  varies 
from  fifteen  weeks  to  eight  years.  The 
patient  gradually  loses  flesh  and  grows 
weaker,  all  the  symptoms  become  aggra- 
vated, hematuria  becoming  prominent, 
causing  marked  secondary  anemia ; 
moderate  edema  of  the  lower  limbs  may 
appear  mainly  as  a  result  of  pressure  on 
some  large  venous  trunk,  and  delirium 
sometimes  precedes  the  terminal  coma. 

DIAGNOSIS.— The  pain  in  the  re- 
gion of  the  affected  kidney,  the  hema- 
turia accompanied  by  frequent  urina- 
tion and  the  localized  tumor,  are  the 
chief  diagnostic  points  among  those  pre- 
viously enumerated,  but  other  features 
may  serve  to  facilitate  the  diagnosis. 
Gelle  pointed  out  that  fragments  of  the 
tumor,  which  is  very  friable  and  often 
dissociated  during  hemorrhages,  could 
be  found  in  the  clots  passed  with  the 
urine.  The  cells  preserve  their  charac- 
ters and  staining  properties. 

As  to  diagnosis  of  the  tumor  itself 
after  removal,  Croftan  found  (1)  that  a 
watery  extract  of  fresh  hypernephroma, 
in  keeping  with  adrenalin  and  adrenal 
extracts,  provoked  glycosuria  when  in- 
jected in  the  rabbit;  (2)  that  a  pure 
starch  solution,  to  which  the  watery  ex- 
tract of  hypernephroma  was  added,  con- 
tained an  appreciable  quantity  of  dex- 
trose; and  (3)  that  the  watery  extract 
also  possesses  the  power  to  decolorize 
an  iodine  starch  solution.    These  simple 


tests  make  it  possiljle  to  differentiate 
hypernei)hronia  from  other  tumors  of 
the  kidney.  This  is  important,  since  the 
post-operative  prognosis  of  hyperne- 
phroma is  much  more  favorable  than 
that  of  any  other  malignant  tumor  of 
the  kidney.  A  high  blood-pressure 
tends  greatly  to  insure  the  diagnosis. 

Hypernephroma  can  be  recognized 
by  the  histological  structure  of  the 
organ,  the  presence  of  oil  globules  in 
the  cells,  and  the  peculiar  staining 
reaction  discovered  by  Lubarsch. 
Case  of  a  man  of  29  years,  who  died 
with  symptoms  of  brain  tumor,  and 
in  whom  masses  of  adrenal  tissue 
were  found  in  the  kidney  and  liver. 
A  careful  study  of  the  literature 
showed  that  hypernephroma  is  more 
common  than  is  usually  supposed. 
Radasch  (Amer.  Jour.  Med.  Sci.,  Aug., 
1902). 

There  are  no  pathognomonic  signs 
of  renal  hypernephroma.  A  diagno- 
sis, ^specially  in  the  early  stages, 
must  be  made  by  a  process  of  exclu- 
sion. Two  personal  cases,  one  of 
which  was  a  boy  of  14,  showed  ex- 
tensive arteriosclerosis.  This  sug- 
gests again  the  importance  of  blood- 
pressure  determinations  in  all  cases 
where  a  suspected  kidney  lesion  ex- 
ists. Hematuria  is  the  most  impor- 
tant early  sign.  Metastasis  occurred 
in  three  instances  as  late  manifesta- 
tions. Only  two  of  the  eight  cases 
were  operated  tipon.  They  have  re- 
mained well  seven  and  fifteen  months 
respectively.  H.  C.  Moffitt  (Boston 
Med.  and  Surg.  Jour.,   Oct.  8,   1908). 

A  question  in  regard  to  these  cases 
which  has  never  been  thoroughly  in- 
vestigated is  that  of  increased  arterial 
tension.  It  is  logical  to  suppose  that, 
with  an  increase  of  adrenal  tissue,  we 
may  have  an  excess  of  adrenal  secre- 
tion, which  would  result  in  a  rise  of 
blood-pressure — certain  writers  have 
noted  that  this  was  true;  but  observa- 
tions upon  this  point  sufficient  to  set- 
tle the  question  have  not  j^et  been 
made.  Every  case  of  hypernephroma 
should  be  thoroughly  investigated  in 


478 


ADRENALS,    DISEASES    OF    (SAJOUS). 


this  regard,  and  we  may  find  that  a 
study  of  the  blood-pressure  furnishes 
us  a  valuable  aid  in  diagnosis.  George 
E.  Beilby  (Albany  Med.  Annals,  Jan., 
1909). 

Various  disorders  may  be  suggested 
by  hypernephroma,  prominent  among 
which  is  urinary  calculus.  In  this  con- 
nection the  pain  is  coincident  with  the 
hemorrhage,  while  in  hypernephroma 
the  pain  continues  after  the  latter, 
though  greatly  relieved.  The  vermicu- 
lar and  cylindrical  shape  of  the  clots  in 
hypernephroma  is  also  suggestive.  Cys- 
toscopic  examination  at  this  time  often 
reveals  these  clots  projecting  from  the 
ureter  of  the  diseased  kidney,  whose 
tumor  can  also,  in  some  instances,  be 
discerned  under  X-ray  examination. 
Pregnancy  is  sometimes  suggested  when 
the  growth  projects  anteriorly,  espe- 
cially in  view  of  the  fact  that  amenor- 
rhea sometimes  precedes  the  abdominal 
enlargement. 

Hypernephroma  may  be  mistaken  for 
enlarged  spleen.  The  latter  is  usually 
nearer  the  surface  and  its  mobility  on 
inspiration  more  marked.  It  is  located 
on  the  left  side,  whereas  hyperne- 
phroma, in  most  instances,  occurs  on 
the  right  side.  Catheterization  of  the 
ureters  may  serve  to  indicate,  between 
the  periods  of  hematuria,  which  of  the 
two  kidneys  is  most  impaired  function- 
ally. The  blood  count  affords  little,  if 
any,  information,  any  diminution  of  red 
corpuscles — sometimes  to  an  extreme 
degree — being  readily  accounted  for  by 
hematuria.  Moderate  leucocytosis  oc- 
curs in  some  cases,  but  not  with  sufifi- 
cient  frequency  to  give  this  sign  any 
diagnostic  importance. 

In  some  cases  the  symptoms  and  phys- 
ical signs,  other  than  hematuria,  afford 
but  little  help  to  establish  the  identity 
of  the  tumor,  either  anteriorly  or  pos- 
teriorly.    In  that  case  the  absence  of 


pregnancy  being  clearly  established,  an 
exploratory  incision  followed  imme- 
diately, if  hypernephroma  be  present, 
by  its  radical  removal,  is  indicated. 

PATHOLOGY.  — Hypernephroma 
is  usually  located  in  the  upper  pole  of 
the  kidney,  immediately,  therefore,  un- 
der the  adrenals.  When  found  early  in 
life  at  autopsies  hypernephromata  may 
be  no  larger  than  lentils,  or  even  smaller, 
but  they  may  attain  the  size  of  a  child's 
head,  growing  outwardly,  or,  in  some 
cases,  inwardly,  at  the  expense  of  the 
renal  tissues.  They  reproduce  more  or 
less  perfectly,  the  adrenal  tissue,  the 
smaller  growths  being  made  up,  as  a 
rule,  of  the  cortex,  and  the  larger  of 
both  the  cortical  and  the  medullary  sub- 
stance. They  are  firm  when  small,  but 
when  they  attain  a  certain  size  their  ten- 
dency is  to  become  lobulated,  the  pro- 
jecting masses  becoming  softer  and 
cyst-like.  They  are  lobulated  owing  to 
the  fibrous  bands  derived  from  the  renal 
capsule,  and  the  lobules,  when  opened, 
may  be  yellowish,  grayish  red,  or  brown 
or  blackish,  and  contain  hemorrhagic 
areas — the  source  of  the  blood  which 
causes  hematuria. 

[The  various  colors  mentioned  correspond 
suggestively  with  the  cutaneous  pigments  I 
have  ascribed  to  the  adrenal  principle  in 
icterus  bronzing,  etc.,  and  this,  in  turn,  fur- 
ther confirms  the  fact  that  the  melanins  are 
mainly  composed  of  this  principle  ("Internal 
Secretions,"  vol.  ii,  p.  835).  Hence  the  asso- 
ciation of  hypernephroma  with  melanotic  sar- 
coma by  various  pathologists.    C.  E.  de  M.  S.] 

The  larger  growths  are  those  which 
tend  to  become  malignant  and  to  pro- 
duce metastases.  These  occur  through 
the  blood-vessels,  both  the  arteries  and 
veins ;  the  bones  and  lungs,  as  previously 
stated,  are  the  structures  most  fre- 
quently invaded,  though,  occasionally, 
extension  occurs  by  the  lymphatics,  in- 
cluding the  retroperitoneal  glands. 


ADRENALS,    DISEASES    OF    (SAJOUS). 


479 


]\Iicroscopically  they  usually  contain 
a  scanty  stroma  composed  of  vascular- 
ized connective  tissue  in  columns  and  a 
parenchyma  formed  of  endothelial 
polygonal  or  columnar,  translucent  nu- 
cleated cells,  which  differ  entirely  from 
those  of  the  renal  epithelium.  The  cyto- 
plasm is  granular  and  contains,  besides 
detritus  and  giant  cells,  numerous  fat- 
laden  vacuoles.  It  is  the  presence  of 
considerable  fat  which  first  caused  these 
tumors  to  be  regarded  as  lipomata.  The 
fat  contains  lecithin.  Glycogen  is  also 
present,  sometimes  in  relatively  large 
quantities. 

Prior  to  1883  many  forms  of  renal 
growths  were  grouped  under  the  head 
of  lipomata.  Some  authors  had  pre- 
viously, and  others  since  that  time, 
described  these  neoplasms  as  adenomata 
arising  from  the  renal  tissue  itself. 
Grawitz  was  the  first  to  bring  order  out 
of  chaos  when  he  maintained  that  these 
growths  formerly  described  as  lipomata 
in  reality  had  their  origin  in  suprarenal 
tissue  misplaced  within  the  kidney.  His 
reasons  for  believing  these  tumors  to 
be  of  adrenal  origin  were:  (1)  the 
subcapsular  position  in  which  aberrant 
adrenal  tissue  is  likely  to  occur;  (2) 
the  cells  were  quite  different  in  form 
from  the  renal  cells,  and  contained  fat- 
globules  in  large  drops  like  fatty  in- 
filtrated liver-cells;  (3)  the  capsule  and 
the  arrangement  of  the  tumor-cells  in 
rows,  like  the  supiarenal  cortex,  the 
preponderance  of  cells  over  stroma; 
(4)  amyloid  degeneration  of  blood-ves- 
sels present  in  his  case  only  in  the 
adrenals.  Others,  like  Chiari,  Lubarsch, 
and  many  others,  supported  Grawitz's 
views  and  added  the  following  criteria : 
(1)  the  similarity  between  tumors  of 
the  adrenal  body  itself  and  these 
growths ;  (2)  the  presence  of  glycogen. 
The  frequency  with  which  portions  of 
the  suprarenal  tissue  are  found  under 
the  true  renal  capsule  and  imbedded  in 
the  renal  cortex  was  shown  to  be  as- 
tonishingly great  by  Grawitz.  L.  L. 
McArthur  and  D.  N.  Eisendrath  (Phila. 
Med.  Jour.,  April  29,  1899).  ' 


Four  personal  cases  illustrating  the 
stages  of  transition  from  the  smallest 
benign  neoplasm,  a  pure  aberrant  ad- 
renal germ  to  the  large  growth  which 
assumes  the  characteristics  of  a  cancer. 

Gradually  as  the  malignant  growth 
is  approached,  the  adrenal  germs  or 
"rests"  lose  their  normal  characters  to 
assume  the  vague  embryonic  cellular 
types.  These  correspond  in  every  way 
with  the  renal  cancers  containing  trans- 
lucent cells  which  certain  classic  writers 
still  consider  as  renal  cancers,  but  which 
in  reality  are  hypernephromata.  E. 
Gelle  (L'Echo  med.  du  Nord,  Aug.  2, 
1908). 

PROGNOSIS.— As  a  rule,  hyper- 
nephromata grow  slowly  at  first,  months, 
and  even  years,  elapsing  before  they 
metastasize  or  show  other  signs  of 
malignancy.  They  may  then  progress 
very  rapidly,  and,  the  hematuria  becom- 
ing continuous,  death  occurs  from 
exhaustion. 

A  case  was  reported  by  Hausemann 
in  a  woitian  60  years  of  age,  in  whom 
the  tumor  had  been  present  fifteen 
years  without  evidence  of  rapid  growth. 
Suddenly  the  tumor  began  to  grow 
rapidly  and  the  hematuria  which  until 
then  had  been  periodical  and  not  pro- 
fuse, became  continuous.  The  patient 
died  of  exhaustion  within  a  few  months. 
Kusmik  (Beitrage  zur  klin.  Chin,  Bd. 
xlv,  S.  185,  1905). 

They  show  a  tendency  to  recur, 
though  years  may  elapse  before  recur- 
rence occurs.  If  recognized  early,  how- 
ever, removal  affords  a  greater  chance 
of  permanent  recovery. 

Out  of  4  cases,  1  of  the  patients  al- 
ready reported  was  known  to  be  well 
seven  months  after  operation ;  another 
has  remained  well  fifteen  months,  but 
the  presence  of  a  varicocele  on  the 
sound  side  renders  his  future  doubt- 
ful. Dr.  Levison  operated  on  a  second 
case  that  remained  well  for  some  years. 
Out  of  24  cases  with  operation  recorded 
by  Albrecht,  8  died  from  the  immediate 
results    of    the   procedure    and    9    soon 


480 


ADRENALS,    DISEASES    OF    (SAJOUS). 


afterward  from  local  recurrence  or 
metastases ;  1  died  of  pneumonia  two 
yea/s  after  operation,  and  autopsy  gave 
no  evidence  of  recurrence.  Only  4  pa- 
tients remained  well  after  three  years, 
and  of  these  1  developed  metastasis 
in  the  occipital  bone  at  the  end  of  four 
years ;  a  second,  metastasis  in  the  scap- 
ula after  four  years  and  three  months; 
a  third,  metastasis  in  the  spine  after 
seven  years.  Only  1  patient  out  of 
the  24  remains  well  after  four  years. 
The  danger  of  metastases  years  after 
operation  renders  prognosis  most  un- 
certain. Claimont  has  recorded  a 
case  of  recurrence  in  the  bronchial 
glands  ten  years  after  removal  of  a 
renal  hypernephroma.  It  must  be  re- 
membered, however,  that  Albrecht  has 
shown  that  there  may  be  but  one  me- 
tastasis, and  removal  of  this  may  lead 
to  a  permanent  cure.  The  dishearten- 
ing results  of  operations  in  the  past 
should  spur  on  the  clinician  to  try  all 
methods  that  may  lead  to  early  recog- 
nition of  the  growths.  H.  C.  Moffitt 
(Boston  Med.  and  Surg.  Jour.,  Oct.  8, 
1908). 

TREATMENT.  —  An  exploratory 

incision  is  warranted,  as  previously 
stated,  when  an  abnormal  growth  in  the 
abdomen  or  in  the  region  of  the  kidney 
occurs  coincidently  with  hemorrhage, 
even  when  other  symptoms  of  hyper- 
nephroma are  not  present.  The  ma- 
jority of  authorities  consider  this  pro- 
cedure advisable  even  when  hemorrhage 
into  the  bladder  cannot  be  accounted 
for.  In  some  cases  discomfort  or  ten- 
sion over  one  kidney,  and  deep  compara- 
tive palpation, on  both  sides  may  suggest 
which  side  should  be  explored  first ;  but 
if  this  unilateral  examination  fails  to  in- 
dicate the  presence  of  a  growth,  ex- 
ploration of  the  other  kidney  is  justifi- 
able. In  some  instances  the  organ  is 
merely  enlarged,  especially  toward  the 
upper  pole,  or  at  the  hilum.  Removal 
of  the  growth  may  be  performed  extra- 
peritoneally  through  a  lumbar  incision. 


The  fatty  capsule  should,  according  to 
Kuzmik,  be  removed  along  with  the 
growth,  as  it  may  be  infiltrated  and  thus 
lead  to  recurrence. 

Case  in  a  woma,n  aged  37,  married, 
who  had  an  abdominal  swelling  the 
size  of  a  fetal  head  at  term.  It  was 
very  mobile  and  fluctuant,  and  could 
not  be  pushed  down  into  the  pelvis. 
A  diagnosis  of  cyst  of  the  kidney  or 
ovarian  cyst  with  a  long  pedicle  was 
made.  On  opening  the  abdomen  the 
tumor  was  found  to  be  retroperito- 
neal and  crossed  by  the  descending 
colon.  The  peritoneum  was  divided 
and  the  cyst  enucleated.  There  was 
no  pedicle.  The  cyst  lay  immediately 
in  front  of  the  left  kidney,  which  was 
normal.  The  patient  made  a  rapid 
recovery.  On  section  the  tumor  con- 
tained blood  and  clots.  The  cyst- 
wall  showed  fibrous  septa  inclosing 
polyhedral  granular  nucleated  cells, 
closely  resembling  the  "zona  glome- 
rulosa"  of  the  normal  suprarenal  cap- 
sule. Archibald  Donald  (Brit.  Med. 
Jour.,  Dec.  9,  1899). 

Two  cases  of  hypernephroma,  both 
of  which  were  absolutely  well  one 
year  after  operation,  a  nephrectomy 
having  been  done  at  that  time.  Keen, 
Pfahler  and  EUis  (Amer.  Med.,  Dec. 
17,   1904). 

An  extraperitoneal  operation  can  be 
done  even  for  the  removal  of  a  very 
large  tumor,  although  it  is  possible  only 
when  the  tumor  has  slowly  grown  into 
the  tissues  of  the  mesocolon,  and  the 
ventral  or  right  peritoneal  surface  of 
the  colon  has  become  greatly  hyper- 
trophied  or  enlarged,  and  the  blood- 
vessels of  'the  colon  so  distorted  that  a 
long  incision  would  not,  in  any  way, 
vitiate  the  blood-supply  of  this  large 
duct.  The.  results  of  a  personal  opera- 
tion also  showed  the  necessity  of  taking 
advantage  of  every  opportunity  to  com- 
pletely remove  a  neoplasm,  no  matter 
how  grave  the  prognosis  may  be  at  the 
time  of  operation.  Bayard  Holmes 
(Med.  Standard,  Nov.,  1904). 

Case  of  hypernephroma  of  the  left 
kidney  in  which  the  following  proved 
successful :      the    patient    having    been 


AGAR-AGAR. 


AGARICIN. 


481 


perfectly  well  fifteen  months  before  the 
present  report.  A  Morris  incision  on 
the  left  side  began  about  2  cm.  outside 
the  quadratus  lumborum  and  extended 
forward  and  downward  to  the  level  of 
the  anterior  superior  spine.  This  neces- 
sitated division  of  the  external  oblique 
muscle.  The  peritoneum  was  pushed 
forward  and  the  kidney  tumor  removed 
after  much  difficult  dissection.  The 
tumor  and  kidney  measured  18  x  10  x  8 
cm.,  and  was  densely  adherent  at  the 
upper  border.  The  vessels  were  ligated 
high  up,  and  on  account  of  the  high 
position  of  the  tumor  the  tips  of  the 
tenth  and  eleventh  ribs  were  divided 
subperiosteally  and  the  diaphragm  raised 
with  retractors.  Most  of  the  capsule 
was  removed  and  the  ureter  was 
stripped  downward,  almost  to  the  blad- 
der, and  cut  short  after  carbolizing  the 
end.  The  vessels  were  large,  but  not 
occluded  by  the  tumor  mass,  and  were 
ligated  by  Pagenstecher.  The  peri- 
toneum was  opened  at  the  upper  end  of 
the  incision,  but  was  easily  closed  with 
continuous  catgut  sutures.  The  hemor- 
rhage was  fairly  severe  from  the  cap- 
sule, but  was  readily  controlled.  The 
remnant  of  the  capsule  was  stitched 
with  catgut  and  a  cigarette  drain  in- 
serted in  the  space.  Muscles  sutured 
with  chromicized  gut,  skin  with  silk- 
worm gut  and  continuous  plain  catgut. 
Sterile  gauze  dressing.  H.  C.  Moffitt 
Boston  Med.  and  Surg.  Jour.,  Oct.  8, 
1908). 

C.  E.  DE  M.  Sajous, 

Philadelphia. 

ADRIN.      See  Animal  Extracts  : 
Adrenals. 


AGALACTIA. 

Gland. 


See  Mammary 


AGAR-AGAR  is  the  East  Indian 
name  of  a  substance  extracted  from 
various  seaweeds,  which  is  available  in  the 
shops  in  the  form  of  long,  transparent 
strips  resembling  goose-quill  pith,  and  also 
in  quadrangular  cakes  weighing  about  150 
grains  (10  Gm.)  each.  It  consists  chiefly 
of  gelose,  and  is  soluble  in  hot  water, 
though   insoluble   in   cold   water.     It   has 


been  extensively  used  as  a  culture  medium 
and  as  a  demulcent,  combined  with  glyc- 
erin for  chapped  hands  and  lips. 

Recently,  however,  it  has  been  used  for 
constipation  in  doses  ranging  from  V/z 
drams  (6  Gm.)  to  Yz  ounce  (8  Gm.), 
coarsely  comminuted  and  mixed  with  food. 
It  becomes  a  jelly  in  the  stomach  and  in- 
testines by  absorbing  water  and,  being  in- 
digestible, gives  considerable  bulk  to  the 
feces,  thus  promoting  defecation  mechan- 
ically. A.  Schmidt  gives  agar-agar  cut  up 
in  small  pieces,  adding  25  per  cent,  of  an 
aqueous  extract  of  cascara  sagrada.  One 
teaspoonful  to  a  tablespoonful  in  mashed 
potatoes  or  any  other  soft  food  is  given 
daily  in  chronic  constipation.  S. 

AGARICIN  is  obtained  from  the 
white  agaric  {Boletus  laricis),  a  fungus 
growing  on  the  trunk  of  the  European 
larch.  The  activity  of  agaricin  is  due  to 
agaricic,  agaricinic,  or  agaric  acid.  The 
pure  acid  occurs  as  a  white,  silky  powder 
made  up  of  minute  prismatic  or  lamellar 
crystals,  and  having  a  bitter  taste.  It  is 
soluble  in  alcohol,  and  in  hot  water,  and 
but  slightly  so  in  cold  water,  ether,  and 
acetic  acid.  It  forms  soluble  salts  with 
the  alkali  metals.  Agaricic  acid  is  the 
preparation  from  agraric  generally  used  in 
therapeutics  under  the  name  of  agaricin. 
The  commercial  agaricin,  on  the  other 
hand,  is  an  impure  resinous  product  ob- 
tained by  extraction  from  the  crude  drug, 
and  is  much  weaker  in  its  effects  than  the 
acid. 

DOSE. — The  dose  of  agaricic  acid  is  M.5 
to  y2  grain  (0.004  to  0.03  Gm.).  It  is 
usually  given  in  pill  form,  but  may  also 
be  administered  hypodermically,  when  the 
dose  should  be  one-half  smaller.  The 
resinous  agaricin  is  sometimes  used,  the 
dose  being  from  1  to  5  grains  (0.065  to 
0.3  Gm.).  The  doses  given  should  at  first 
be  small;  they  can  then  gradually  be  in- 
creased as  the  patient  becomes  partially 
tolerant  to  the  effects  of  the  drug. 

PHYSIOLOGICAL  ACTION.— Agar- 
icic acid  in  therapeutic  doses  decreases 
markedly  the  activity  of  the  sweat-glands. 
It  probably  acts  on  the  secretory  nerve- 
endings  to  these  glands  (Hofmeister),  thus 
resembling  atropine  in  its  action.  It  ex- 
erts, however,  no  inhibiting-  influence  on 
-31 


482 


AGGLUTINATION    TEST. 


the  other  secretions  of  the  body,  including 
the  salivary  secretion,  and  does  not  aflfect 
the  pupils.  In  larger  doses  it  causes  purg- 
ing and  sometimes  vomiting  by  an  irri- 
tating effect  on  the  gastrointestinal  tract. 
No  serious  constitutional  results  are  ever 
produced  by  it  when  used  internally  be- 
cause of  the  slowness  with  which  it  is 
absorbed.  It  has  no  cumulative  action. 
Toxic  effects  from  it  may  be  observed, 
however,  upon  its  intravenous  injection  in 
large  doses  into  animals,  and  less  readily 
upon  subcutaneous  injection.  It  excites 
primarily,  and  secondarily  causes,  pro- 
gressive paralysis  of  the  bulbar  centers,  in- 
cluding the  vagal  and  vasomotor  centers. 
The  animal  shows  marked  weakness,  be- 
comes dyspneic,  has  convulsions,  and  dies 
as  a  result  of  paralysis  of  the  respiratory 
center.  Subcutaneous  injections  of  agar- 
icic  acid  produce  inflammation  of  the  sur- 
rounding tissues,  sometimes  followed  by 
abscess  formation.  When  applied  to 
abraded  areas  or  to  mucous  membranes  it 
acts  as  a  local  irritant. 

THERAPEUTICS.— Agaricin  (agaricic 
acid)  is  of  great  value  in  the  treatment  of 
the  night-sweats  of  pulmonary  tuber- 
culosis. Doses  of  Yq  to  3^  grain  (0.01  to 
0.03  Gm.)  are  generally  effective;  accord- 
ing to  Conkling,  Yio  grain  (0.005  Gm.)  will 
often  suffice.  Where  the  gastric  diges- 
tion is  good,  it  is  well  tolerated,  and  often 
causes  diminution  or  even  complete  dis- 
appearance of  the  sweats  (Andral,  Leguu- 
geux),  especially  in  the  second  and  third 
stages  of  the  disease  (Combemale).  The 
action  begins  two.  hours  or  more  after 
administration,  and  reaches  its  height 
three  hours  later.  Taken  before  retiring, 
agaricin  will  sometimes  prevent  the  oc- 
currence of  a  night-sweat,  thereby  re- 
lieving the  patient  from  the  consequent 
exhaustion. 

While  not  as  certain  a  remedy  as  atro- 
pine, it  is  advantageous  in  not  causing  the 
other  unpleasant  effects  of  the  latter,  such 
as  drying  of  the  mouth  and  fauces,  nausea, 
and  dilated  pupils.  It  may  be  given  in 
combination  with  aromatic  sulphuric  acid, 
which  has  a  similar  action  in  reducing 
sweats.  Where  agaricin  is  found  to  cause 
gastrointestinal  irritation  and  a  tendency 
to  diarrhea,  it  is  sometimes  prescribed 
with  small   amounts   of  some  preparation 


of  opium, — Dover's  powder,  for  example. 
Agaricin  is  used  to  counteract  excessive 
sweating  from  other  causes  than  phthisis, 
including  various  infections  and  intoxica- 
tion by  certain  drugs  (coal-tar  antipy-. 
retics,  salicylates).  It  has  also  been  em- 
ployed to  arrest  the  secretion  of  milk.  Its 
action  can  be  kept  up,  if  desired,  by  giv- 
ing small  doses  repeatedly.  S. 

AGGLUTINATION    TEST. 

— This  test,  also  known  as  the  Widal  re- 
action or  the  Gruber-Widal  reaction,  is 
used  to  establish  the  presence  of  typhoid 
fever.  It  is  based  upon  the  fact  that  in 
this  disease  the  specific  bacteria  in  free 
dilution  "agglutinate,"  that  is  to  say,  ad- 
here to  one  another  and  lose  their  motile 
power,  thus  forming  clumps  or  masses  in 
the   solution   examined. 

The  essential  feature  of  this  test  is  that, 
while  normal  serum,  i.e.,  the  serum  of  a 
normal  individual,  when  diluted  up  to  a 
certain  limit,  will  agglutinate  many  bac- 
teria besides  the  typhoid  bacillus,  the  lat- 
ter organism  causes  the  production  of  so 
great  a  quantity  of  the  substance  "agglu- 
tinin," which  provokes  the  phenomenon, 
that,  even  when  a  drop  of  serum  from  a 
typhoid  patient  is  diluted  SO  times  or  more 
with  saline  solution,  agglutination  of 
typhoid  bacteria,  obtained  from  a  recent 
culture  of  these  germs,  will  occur.  The 
reaction  is  only  reliable,  in  fact,  when  the 
degree  of  dilution  is  not  below  1  to  50. 

The  microscopic  reaction  requires  a  slide 
with  a  concave  depression  in  the  middle 
of  one  of  its  surfaces.  A  small  quantity 
of  the  patient's  serum  is  obtained  by  prick- 
ing the  ear  or  the  finger.  This  quantity 
is  diluted  in  fifty  times  its  volume  of 
saline  solution.  A  drop  of  this  is  then 
placed  on  a  cover-glass,  with  a  drop  or 
loopful  of  fresh  bouillon  of  genuine 
typhoid  bacilli.  The  cover-glass  is  then 
inverted  and  placed  over  the  concavity  of 
the  slide  in  such  a  way  as  to  cause  the 
mixture  to  hang  downward.  Hence  the 
term  "hanging  drop"  method.  The  edges 
of  the  cover-glass  being  then  sealed  with 
paraffin  or  vaselin,  the  slide  is  examined 
under  the  microscope,  using  the  one- 
twelfth  oil-immersion  lens,  and  the  clamp- 
ing and  loss  of  motility  of  the  typhoid 
bacilli   ascertained.     If  more  than  4  bac- 


AGURIN. 


AINHUM. 


483 


tenia  are  permanently  ac^sUitinatcd,  the 
test  is  positive. 

This  method  is  only  applicable,  however, 
in  hospitals,  where  a  clinical  microscope  is 
available,  unless  the  physician  carries  his 
microscope  to  the  patient's  home.  This 
inconvenience  can  be  readily  obviated, 
however,  by  dipping  a  piece  of  absorbent 
paper  in  the  patient's  blood.  When  dried 
this  paper  can  be  used  for  the  test  by 
placing  it  in  forty  to  fifty  times  the  quan- 
tity of  saline  solution  that  the  paper  con- 
tains of  serum.  The  latter  \n\\  then  dis- 
solve in  the  saline  solution,  and  a  drop  of 
the  mixture  with  the  drop  of  typhoid 
bacilli  culture  can  then  be  used  as  de- 
scribed above. 

Or  again,  "3  drops  of  blood  are  taken 
from  the  well-washed  aseptic  finger-tip 
or  lobe  of  the  ear,  and  each  lies  by  itself 
on  a  sterile  slide,  passed  through  a  flame 
and  cooled  just  before  use;  this  slide  may 
be  wrapped  in  cotton  and  transported  for 
examination  at  the  laboratory.  Here  one 
drop  is  mixed  with  a  large  drop  of  sterile 
water  to  redissolve  it.  A  drop  from  the 
summit  of  this  is  then  mixed  w^ith  6  drops 
of  fresh  broth  culture  of  the  bacillus  (not 
over  twenty-four  hours  old)  on  a  sterile 
slide.  From  this  a  small  drop  of  mingled 
culture  and  blood  is  placed  in  the  middle 
of  a  sterile  cover-glass,  and  this  is  in- 
verted over  a  sterile  hollow  ground  slide 
and  examined.  A  positive  reaction  is  ob- 
tained when  all  the  bacilli  present  gather 
in  one  or  two  masses  or  clumps  and  cease 
their  rapid  movement  inside  of  twenty 
minutes"  (Green-Hughes). 

The  test  may  also  be  carried  out  without 
the  aid  of  a  microscope;  this  is  the  mac- 
roscopic reaction.  Several  bouillon  cultures 
being  available,  5  c.c.  of  each  culture  are 
placed  in  as  many  test-tubes  as  there  are 
cultures.  To  each  test-tube  is  then  added 
sufficient  serum  of  the  suspected  case  to 
obtain  a  solution  of  1  to  SO.  The  test- 
tubes  are  then  kept  at  blood  or  room  tem- 
perature from  three  to  seven  hours. 
Their  contents  will  then  have  become 
clearer,  the  bacilli  having  been  precipitated 
to  the  bottom  of  each  test-tube  if  the 
reaction  is  positive.  It  is  obvious,  how- 
ever, that  the  microscopic  reaction  is  pref- 
erable and  less  liable  to  mislead. 

That  the  value  of  the  Widal  reaction  is 


very  great  is  now  generally  recognized. 
Kncass  and  Stengel  in  statistics  based  on 
over  2000  cases  give  95.2  per  cent,  as  the 
proportion  in  which  true  cases  of  typhoid 
fever  had  given  a  positive  reaction,  while 
no  reaction  occurred  in  98  per  cent,  of  the 
cases  which  eventually  did  not  prove  to  be 
typhoid.  Abbott,  in  statistics  based  on 
4154  cases  for  which  the  Widal  reaction 
was  taken  in  the  municipal  laboratories  of 
Philadelphia,  places  at  only  2.8  per  cent, 
the  possibility  of  error.  S. 

AGORAPHOBIA.     See  Index. 

AGURIN, a  diuretic,  is  a  double  salt  of 
theobromine  sodium  and  sodium  acetate, 
which  contains  60  per  cent,  of  theobromine. 
It  occurs  in  the  form  of  a  fine  crystalline 
powder,  which  is  freely  soluble  in  water,  and 
but  slightly  so  in  cold  alcohol. 

MODES  OF  ADMINISTRATION.— 
Agurin  is  hydroscopic  and,  in  aqueous  solu- 
tion, readily  splits  into  its  components. 
Hence,  the  advisability  of  prescribing  it  in 
capsules  or  in  tablets,  5-grain  tablets  being 
available  in, the  shops.  The  dose  is  from  5 
to  10  grains  (0.3  to  0.6  Gm.)  three  to  five 
times  a  day.  It  is  also  absorbed  from  the 
rectum  when  given  in  an  enema  of  plain 
water. 

THERAPEUTICS.— Agurin  is  especially 
efficacious  as  a  diuretic  in  cardiac  dropsy  and 
acts  well  in  combinatioi  with  digitalis.  It 
acts  like  theobromine  (q.  v.)  and  is,  unlike 
diuretin,  well  borne  by  the  stomach.  It  also 
gives  good  results  in  interstitial  nephritis, 
especially  when  combined  with  the  milk  diet. 
This  applies  also  to  hepatic  cirrhosis,  though 
to  a  less  marked  degree.  Agurin  presents  the 
advantage  of  promoting  diuresis  without 
increasing  the  blood-pressure,  a  property 
which  renders  it  particularly  useful  in 
cases  of  dropsy  of  cardiac,  renal,  or  hepatic 
origin  in  which  arteriosclerosis  renders 
diuretics  which  raise  the  blood-pressure 
dangerous.  S. 

AINHUM. — African  word  meaning 
"to   saw  off." 

DEFINITION.— Ainhum  is  a  disease 
occurring  exclusively  in  negroes  and  con- 
sisting in  the  spontaneous  amputation  of 
the  little  toe  by  an  adventitious  fibrous, 
band. 


484 


AINHUM. 


SYMPTOMS.— The  first  indication  of 
the  disease  is  a  furrow  on  the  lower  sur- 
face of  the  little  toe,  and  occasionally 
other  toes,  at  the  proximal  interphalangeal 
joint.  This  furrow,  the  result  of  the  cir- 
cumferential pressure  exerted  by  a  fibrous 
ring,  gradually  deepens  until  the  bone  is 
reached,  this  process  taking  several  years, 
sometimes  as  many  as  ten.  The  distal 
portion  of  the  toe  becomes  greatly  liyper- 
trophied,  then  finally  drops  off,  the  stump 
healing  without  further  complications  in 
the  great  majority  of  cases.  It  does  not 
give  rise  to  much  suffering,  owing  to  its 
very  gradual  progress.  It  is  sometimes 
mistaken  for  leprosy.  It  has  been  ob- 
served in  the  white  race  also. 

Though  rare  in  the  United  States, 
ainhuni  is  so  common  in  India  that 
Crawford  found  a  case  in  every  two 
thousand  surgical  patients  in  Indian 
hospitals.  The  absence  of  pain  or 
inconvenience  in  many  cases  also 
probably  prevents  their  being  re- 
ported. The  ultimate  result  of  the 
disease,  which  begins  as  a  crack  or 
fissure,  is  the  spontaneous  amputa- 
tion of  one  or  more  fingers  or  toes 
by  a  gradiial  circular  strangulation. 
In  the  writer's  case,  complete  ampu- 
tation of  one  toe  and  partial  amputa- 
tion of  another  had  occurred  before 
the  patient  sought  medical  assistance 
or  appreciated  his  condition.  It  is 
rare  in  females,  and  is  almost  ex- 
clusively confined  to  the  dark-skinned 
races,  only  4  cases  having  been  re- 
ported in  whites.  It  is  probably  a 
trophoneurosis  of  unknown  origin. 
N.  D.  Brayton  (Jour.  Amer.  Med. 
Assoc,  July  8,  1905). 

Case  of  ainhum  in  a  white  girl  in 
Florida.  The  case  is  of  interest  be- 
cause of  the  appearance  of  ainhum 
in  the  Southern  States  and  heretofore 
reported  in  the  negro  race  only. 
When  ulceration  takes  place  the  ulcer 
assumes  a  resemblance  of  a  necrotic 
ulcer  with  a  distinct  nauseous  color. 
As  advanced  by  Unna,  the  condition 
is  a  sclerodermic  callosity,  with  ring 
formation,  producing  a  stagnating 
necrosis.  The  tumefaction  indicates 
a    stagnation,   resulting    in    degenera- 


tion, retraction,  and  finally  disappear- 
ance of  the  phalanges.  The  disease 
sometimes  covers  a  period  of  several 
years.  Eskridge  (Med.  Rec,  Sept.  17, 
1910). 

Two  cases  of  ainhum  that  the 
writer  has  cared  for-at  Garfield  Hos- 
pital Dispensary.  He  watched  the 
progress  of  the  case  for  two  years, 
and  showed  photographs  and  skia- 
graphs of  them,  taken  at  the  begin- 
ning and  end  of  observation.  One 
case,  in  a  negress,  a  native  of  Mary- 
land, was  of  sixteen  years'  duration, 
but  only  slightly  advanced.  The  pain 
in  the  crack  was,  however,  sufficient 
to  indvice  her  to  have  the  toe  ampu- 
tated. The  specimen  showed  the 
groove  in  the  soft  tissues  and  the 
slight  atrophy  of  bone. 

The  other  case,  also  in  a  negress,  a 
native  of  Georgia  who  had  lived 
fifteen  years  in  the  District  of  Colum- 
bia, was  of  about  twenty-five  j^ears' 
duration  and  much  more  marked  than 
the  other  case;  the  groove  around  the 
toe  was  deepest  on  the  plantar  and 
inner  margins  of  the  toe  and  had 
penetrated  almost  to  the  toe-nail. 
The  middle  phalanx  was  practically 
gone;  only  the  nail-bearing  part  of 
the  ungual  phalanx  remained;  the 
basal  phalanx  was  atrophied  about 
one-half.  The  advance  of  absorption 
of  bone  was  quite  plain  in  the  skia- 
graphs. The  skin  of  the  feet  and 
hands  showed  a  scaly  condition.  As 
the  toe  had  given  but  little  pain,  the 
patient  declined  to  have  it  amputated, 
and  was  therefore  presented  herself. 
Truman  Abbe  (Washington  Med. 
Annals,  Nov.,  1910). 

ETIOLOGY.— Ainhum  is  always  ob- 
served in  negroes,  especially  of  the  west- 
ern coasts  of  Africa  and  South  America. 
A  number  of  cases  have  also  been  reported 
in  the  United  States  by  Bringier.  Hin- 
doos are  said  to  also  suffer  from  the  dis- 
ease. Self-mutilation  has  been  suggested 
by  some  observers,  but  the  likelihood  of 
this  cause  is  very  slight.  Heredity  does 
not  seem  to  play  any  role  in  its  production. 

PATHOLOGY.— The  lesions  observed 
have    been    hypertrophic    thickening    and 


AIROL. 


485 


retraction  of  the  derma,  with  consequent 
atrophy  of  the  underlying  hone  (ITerniann, 
Weber,  Wuchcrer,  SchiippeO.  It  has  been 
confounded  with  congenital  amputation, 
but,  as  stated,  ainhum  is  never  congenital. 
That  the  disease  bears  some  connection 
with  leprosy  is  insisted  upon  by.  some 
authorities.  According  to  Zambaco  Pacha, 
undoubted  symptoms  of  leprosy  are  pres- 
ent in  all  cases  of  true  ainhum.  It  should 
be  looked  upon  as  an  attenuated  form  of 
the  latter  disease.  Its  relations  to  sclero- 
derma are  explained  by  the  fact  that  this 
latter  affection  is  a  special  form  of  leprosy. 
It  has  also  been  attributed  to  syphilis, 
larvas,  and  atavism. 

The  writer  agrees  with  Matas  in 
terming  ainhum  a  trophoneurosis. 
Personal  case  in  a  negress  of  65 
years  whose  right  little  toe  was 
affected  in  the  characteristic  way. 
The  toe  was  disarticulated  at  the 
metatarsophalangeal  joint  under  co- 
caine anesthesia,  and  the  cicatrix  has 
since  remained  in  healthy  condition. 
H.  N.  Blum  (Med.  Record,  Oct.  22, 
1904). 

No  definite  and  undisputed  cause 
for  the  lesion  has  yet  been  proved,  but 
the  writer  thinks  that  there  is  most 
to  be  said  in  favor  of  de  Silva  Lima's 
view  that  it  is  due  to  traumatism. 
The  splay-footed  negro  is  especially 
liable  to  such,  and  the  groove  around 
the  toe  in  this  disease,  both  macro- 
scopically  and  histologically,  is  a 
cicatrix.  The  later  fatty  and  atrophic 
conditions  in  the  amputated  toe  are 
not  yet  fully  explained,  but  may  de- 
pend on  local  cicatricial  formations 
or  may  be  of  trophic  origin.  Well- 
man  (Jour.  Amer.  Med.  Assoc, 
March  3,   1906). 

TREATMENT.  —  Surgical  measures 
alone  prove  of  value  in  these  cases.  Early 
section  of  the  fibrous  ring  is  sometimes 
sufficient  to  arrest  the  progress  of  the  dis- 
ease, or  division  of  the  skin  down  to  the 
periosteum  on  the  opposite  side  of  the 
seat  of  the  disease  may  be  resorted  to. 

Murray  successfully  treated  a  case  by 
dividing  the  skin  and  all  the  tissues  down 
to  the  periosteum,  on  the  side  opposite  to 
-the  seat  of  the  disease.  S. 


AIROL  or  bismuth  oxyiodogallate 
[Coll:.,  (0H)3.  COO.  BilOH],  is  a  compound 
of  gallic  acid  and  bismuth  subiodide.  It 
occurs  in  the  form  of  a  bulky,  grayish-green 
powder,  devoid  of  odor  or  taste.  It  is  in- 
soluble in  water,  alcohol,  chloroform,  and 
ether,  but  is  slightly  soluble  in  glycerin  and 
is  dissolved  in  alkaline  solutions  and  dilute 
mineral  acids.  When  exposed  to  moisture, 
including  wound  secretions,  it  is  gradually 
changed  into  a  reddish  powder,  due  to  the 
liberation  of  a  portion  of  its  iodine :  this 
change  occurs  with  great  rapidity  when  boil- 
ing water  is  applied  to  airol. 

MODES  OF  ADMINISTRATION.— 
Internally  airol  has  sometimes  been  given  in 
doses  of  2  to  5  grains  (0.13  to  0.32  Gm.). 
Externally  it  is  used  principally  in  the 
powder  form,  which  is  dusted  over  the  sur- 
face involved  after  it  has  been  washed  with 
hydrogen  peroxide  or  other  cleansing  agent. 
It  may  also  be  applied  in  an  ointtpent  con- 
taining about  2  to  4  drams  of  airol  to  the 
ounce  of  petrolatum,  or  in  a  10  per  cent, 
glycerin  emulsion  containing  equal  parts  of 
glycerin  and  water.  The  latter  preparation 
may  be  injected  in  septic  areas.  In  the 
treatment  of  skin  lesions  it  has  been  applied 
as  a  paste  containing  2  parts  each  of  glyc- 
erin and  mucilage  to  1  part  of  airol,  mixed 
with  a  sufficient  amount  of  refined  clay  or 
kaolin  (Brun's  paste).  Airol  has  also  been 
used  as  a  vaginal  suppository.  An  airolated 
gauze  (20  per  cent.),  similar  to  iodoform 
gauze,  is  frequently  employed.  The  fact 
that  this  substance  is  decomposed  by  free 
contact  with  water  should  always  be  kept  in 
mind. 

PHYSIOLOGICAL  ACTION.  — When 
used  internally  or  by  injection  in  large 
amounts,  airol  has  been  known  to  cause 
symptoms  similar  to  those  of  bismuth  poison- 
ing. Thus  Semmer  witnessed  a  case  in 
which  55  grains  of  airol  az  a  10  per  cent, 
solution  in  olive  oil  injected  into  an  abscess, 
resulted  within  three  days  in  softening  of 
the  gums,  darkening  of  the  buccal  mucous 
membrane,  foul  breath,  headache,  nausea, 
and  prostration.  Marked  irritative  effects 
have  also  been  observed  (Zelemsky,  Gold- 
farb),  though  a  total  amount  of  15  grains 
taken  within  three  days  was  found  by 
Haegler  to  cause  no  unpleasant  effects. 

THERAPEUTICS.— Airol  is  valuable  ex- 
ternally  as   an  antiseptic,  astringent,  desic- 


486 


ALBARGIX. 


ALBUMINURIA    (LEVISOX    AND    ERLAXDSEX). 


cant,  and  protective.  Its  germicidal  proper- 
ties are  mainly  due  to  the  liberation  of  iodine 
upon  exposure  to  moisture. 

Haegler  considers  airol  the  equal  of  iodo- 
form in  disinfecting  power,  and  it  has  the 
added  advantage  of  being  without  odor.  It 
is  frequently  used  as  an  antiseptic  dressing 
for  open  wounds,  including  surgical  wounds, 
and  generally  causes  no  pain  when  applied. 
It  has  been  applied  to  infected  ulcers  of 
different  kinds,  varicose  ulcers  (Fahm), 
burns  of  the  second  degree,  and  to  the 
lesions  of  various  skin  diseases,  such  as 
intertrigo  (de  Sanctis),  etc.  It  has  proven 
useful  when  injected  with  glycerin  in  ab- 
scesses of  pyogenic  or  primarily  tuberculous 
origin. 

In  ulcerations  of  the  cornea,  airol  has 
been  applied  in  powder  form  with  success 
(Gallemaerts,  Bonivento). 

Airol  has  been  used  for  the  treatment  of 
uterine  and  vaginal  inflammations.  It  may 
be  incorporated  in  the  usual  cocoa-butter 
suppositories  for  vaginal  use,  or  introduced 
into  the  uterus  and  vagina  on  gauze  moist- 
ened with  a  liquid  mixture.  Delbert  dips  a 
wick  of  aseptic  gauze  in  a  1  to  4  emulsion  of 
airol  in  glycerin  and  inserts  it  through  the 
previously  dilated  cervix  into  the  uterine 
cavity;  he  then  packs  the  vagina  with 
tampons  of  absorbent  cotton  dipped  in  a  1  to 
20  emulsion,  and  does  not  remove  it  for 
forty-eight  hours    (Manquat). 

Airol  may  be  given  where  an  astringent 
effect  on  the  intestinal  tract  is  desired. 
Fahm  has  recommended  its  use  in  tuber- 
culous enteritis.  S. 

ALBARGIN,  or  gelatose  silver,  an 
antiseptic  and  germicide,  is  a  compound 
of  silver  nitrate  15  parts  and  gelatose  85 
parts.  It  occurs  as  a  light,  browaiish-3^el- 
low,  shining  powder,  w^hich  is  freely  solu- 
ble in  equal  parts  of  both  cold  and  hot 
water,  making  a  permanent  solution  if  not 
exposed  to  light.  It  is  incompatible  with 
ferric  and  ferrous  chlorides,  tannin,  opium, 
resins,  and  the  essential  oils. 

THERAPEUTICS.— Albargin  is  mainly 
used  as  a  substitute  for  silver  nitrate  in 
the  treatment  of  gonorrhea.  Its  aqueous 
solutions  being  neutral,  it  may  be  used  as 
injections  in  strengths  from  ^  to  2  per 
cent.  Its  molecule  being  smaller  than  that 
of  albuminous  preparations  of  silver,  it  is 


thought  to  penetrate  more  thoroughly  and 
promptly  the  diseased  tissue  and  destroy 
the  gonococci  therein.  Albargin  has  also 
been  found  efficacious  in  the  treatment  of 
chancroids.  Its  use  is  painless,  and  it  does 
riot  irritate  mucous  membranes;  it  may 
safely  be  used,  therefore,  in  the  treatment 
of  gonorrheal  ophthalmia.  S. 

ALBUMINURIA.  —  D  E  F I  N  I  - 

TION. — The  presence  of  albumin  in 
the  urine,  a  condition  now  known 
to  occur  under  many  circumstances 
without  necessarily  indicating-  the 
presence  of  serious  morbid  changes 
in  the  kidney. 

Albuminuria  may  be  true — when  the 
albumin  is  dissolved  in  the  urine — or 
spuvious,  when  caused  by  admixture  of 
semen,  pus,  or  blood  in  the  urine. 
Spurious  albuminuria  is  easily  dis- 
tinguished from  the  true  form  by 
the  aid  of  the  microscope.  Both 
kinds  of  albuminuria  may  occur 
simultaneously. 

Domenico  Cotugno  discovered,  in 
1770,  that  urine  may  contain  albumin; 
by  boiling  a  sample  of  urine  he  found 
that  pure  albumin  was  precipitated. 
It  was  long  maintained  by  all  authors 
that  albuminuria  was  always  a  symp- 
tom of  disease,  but  of  late  many 
authorities  have  admitted  that  albu- 
minuria may  be  compatible  with  per- 
fect health. 

Posner  maintains  that  albumin  is 
always  found  in  the  urine,  but 
normally  in  too  small  quantity  to  be 
revealed  by  the  ordinary  reagents. 
To  demonstrate  the  presence  of  albu- 
min in  normal  urine  Posner  evapo- 
rated large  quantities  of  urine  at  low 
temperature  and  tried  the  different 
reagents  in  the  concentrated  urine. 
His  experiences  were  repeated  and 
his  views  supported  by  Senator  and 
by     Leube,     who,     however,     did    not 


ALBUMINURIA    (LEVISON    AND    ERLANDSEN). 


487 


find  all)umin  in  all  cases.  Von  Noor- 
den,  Winternitz,  Lecorche,  Talamon, 
and  other  authors  do  not  admit  that 
albumin  is  a  constituent  of  the  normal 
urine;  but  this  was  recently  denied 
by  Morner,  who  found  that  it  inva- 
riably containetl  at  least  22.78  mg. 
(about  3.5  of  a  minim)  per  liter. 

Different  kinds  of  albumin  may  be 
present  in  the  urine;  generally  the 
proteids  contained  in  the  blood-serum 
are  to  be  found, — viz.:  (1)  the  serum- 
albumin,  and  (2)  the  globulin,  or 
paraglobulin ;  in  most  cases  both 
these  proteids  are  present,  but  in 
varying  proportions.  In  some  cases 
there  may  also  be  found  (3)  hemial- 
bumose,  or  propeptone,  a  mixture  of 
different  albumoses  which  are  not 
precipitated  by  boiling;  (4)  nucleo- 
albumin,  which  has  also  erroneously 
been  called  "mucin,"  and  (5)  peptone. 
Joachim  found  pseudoglobulin  in 
every  case  of  albuminuria,  while  eu- 
globulin  was  often  absent.  The. 
albumin  content  mostly  exceeds  that 
of  the  globulin. 

The  writer  carefully  estimated  the 
amount  of  serum-albumin,  of  euglobulin, 
and  of  pseudoglobulin  in  various  forms 
of  albuminuria,  by  means  of  fractional 
precipitation  with  sulphate  of  ammonia, 
and  subsequent  determination  of  nitro- 
gen by  Kjeldahl's  method.  Euglobulin 
•  was  never  found  in  febrile  albuminuria. 
The  globulinic  index  cannot  be  accepted 
as  a  guide  in  the  discrimination  of 
various  kinds  of  albuminuria,  a.s  it 
varies  in  such  wide  limits  in  cases 
which  are  closely  akin  to  each  other. 
No  reliance  can  be  placed  on  the  albu- 
minoid index  as  a  prognostic  criterion, 
for,  although  sometimes  it  was  higher 
in  cases  where  the  kidneys  were  com- 
paratively free  from  disease,  the  re- 
verse was  the  case  at  other  times.  The 
author  did  not  find  a  marked  increase 
in  globulin  in  acute  nephritis,  febrile 
albuminuria,  orthostatic  albuminuria, 
and     the     albuminuria     of     pregnancy. 


Balocco    (Gazz.    deg.    Ospcd.,    Jan.    28, 
1906). 

The  urine  may,  of  course,  also 
contain  albumin  in  connection  with 
hematuria  and  hemoglobinuria,  but 
such  cases  cannot  be  classed  as  true 
albuminuria. 

PHYSIOLOGICAL  ALBUMI- 
NURIA.— Regarding  the  origin  of 
the  albumin  in  the  urine  only  guesses 
can  be  made ;  two  theories  are  pos- 
sible:  (1)  the  albumin  may  come  from 
the  glomeruli;  (2)  from  the  tubular 
epithelial  cells. 

Formerly  the  opinion  predominated 
that  the  fluid  which  escaped  from  the 
glomeruli  was  albuminous,  but  that  the 
albumin  was  absorbed  during  the  pas- 
sage through  the  healthy  renal  tubules, 
diseased  tubular  epithelium  being  unable 
to  absorb  the  albumin.  This  has  not 
been  proved,  however,  and  most  modern 
authors  believe  that  albumin  is  not 
contained  in  the  urine  coming  from 
the  glomeruli,  except  when  these  are 
diseased  or  when  the  pressure  of  blood 
in  the  glomeruli  is  abnormally  great. 
Runeberg,  on  the  contrary,  is  of  the 
opinion  that  albuminuria  is  caused  by 
low  pressure  of  blood,  and  supports  this 
opinion  by  experiments  with  animal 
membranes,  but  experiences  with  dead 
membranes  cannot  be  regarded  as  con-, 
elusive  for  the  action  of  the  living' 
kidney. 

Von  Noorden  and  other  authors  re- 
gard the  tubular  epithelium  as  the 
unique  source  of  albuminuria.  These 
epithelial  cells  are  subject  to  successive 
disintegration:  when  this  is  minimal, 
and  successive  traces,  only,  of  albumin 
are  found  in  the  urine,  the  albuminuria 
is  physiological;  when  the  disintegra- 
tion of  the  tubular  epithelial  cells  is 
augmented  and  hastened  by  disease,  a 
morbid    albuminuria    takes    place.     In 


488 


ALBUMINURIA    (LEVISON    AND    ERLANDSEN). 


his  opinion,  this  theory  is  supported  by 
the  fact  that  nucleoalbumin,  of  which 
the  protoplasm  of  the  cells  undoubtedly 
is  the  source,  is  always  found  in  nor- 
mal urine. 

Senator  considers  physiological  al- 
buminuria in  the  same  light  as  physio- 
logical glycosuria,  and,  among  the 
causes  that  give  rise  to  it  in  susceptible 
individuals,  he  mentions :  severe  exer- 
tion of  the  lower  extremities,  eating 
and  digestion  of  hearty  meals,  men- 
struation, cold  baths,  psychical  excite- 
ment, etc.  He  deems  albuminuria 
pathological  only  when  it  does  not 
disappear  promptly  on  the  cessation 
of  the  particular  stimulus  that  caused 
it.  Physiological  and  allied  forms  of 
albuminuria  are  attributed  to  con- 
genital predisposition  of  the  individ- 
ual to  disease  of  any  organ  which 
directly  or  indirectly  may  influence 
the  elimination  of  albumin. 

The  occurrence  of  albuminuria  is  to 
be  regarded  as  pathological  only  when 
it  does  not  take  place  under  unusual 
conditions  alone,  and  does  not  dis- 
appear promptly  on  the  cessation  of 
the  particular  stimulus  that  caused  it. 
Orthostatic  albuminuria  is  distinctly 
pathological,  and  most  cases  of  this 
or  cyclical  albuminuria  are  caused  by 
a  slight  irritation  or  inflammatory  state 
of  the  kidneys,  which  may  go  on  to 
recovery  or  may  develop  into  a  chronic 
diffuse  nephritis.  Physiological  and 
allied  forms  of  albuminuria  are  based 
upon  congenital  or  acquired  predispo- 
sition of  the  individual,  which  consists 
in  an  abnormality  of  various  organs, 
such  as  the  kidneys,  the  digestive  tract, 
the  blood-vessels,  or  the  body  fluids. 
Senator  (Deut.  med.  Woch.,  Dec.  8, 
1904). 

Study  of  the  albumin  in  the  urine  of 
normal  children.  In  each  specimen  of 
urine,  the  writers  determined  the  color, 
the  appearance,  the  specific  gravity,  the 
reaction  (in  twenty-four-hour  speci- 
mens,   the   total   acidity),    the   presence 


or  absence  of  albumin,  sugar,  acetone, 
diacetic  acid,  indican,  urobilinogen,  and 
phenol ;  and  microscopically,  the  pres- 
ence or  absence  of  cells,  casts,  cylin- 
droids,  and  crystals.  Four  hundred  and 
forty-five  specimens  of  urine  were  ex- 
amined. These  were  obtained  from 
124  children,  ran£ing  in  age  from  18 
months  to  14  years.  During  the  period 
of  examination  the  usual  routine  of 
life  was  followed,  except  that  the 
children  were  kept  from  school.  There 
was  no  relationship  between  the  specific 
gravity  and  thf^  form  or  amount  of 
albumin.  The  reaction  had  no  influence 
on  the  production  of  albumin.  Sugar, 
acetone,  and  diacetic  acid  were  never 
found.  They  may,  therefore,  be  con- 
sidered as  having  no  bearing  on  the 
production  of  albumin.  Indican,  phe- 
nol, and  urobilinogen,  when  present, 
were  usually  associated  with  albumin, 
but  albumin  was  soinetimes  absent  when 
they  were  all  present,  and  the  amount 
was  never  greater  when  associated  with 
them  than  it  was  in  the  cases  in  which 
they  were  absent.  Crystals,  when  pres- 
ent in  amounts,  such  as  are  occasionally 
found  in  normal  children,  are  in  no  way 
responsible  for  the  associated  albumin. 
The  mild  disturbances  of  the  intestinal 
digestion,  as  shown  by  the  examination 
of  the  stools,  were  not  sufficient  to 
account  for  the  occurrence  of  albumin. 
The  blood-pressure  was  within  the 
normal  range  in  all  cases  and,  there- 
fore, did  not  influence  the  albumin  out- 
put. The  albumin  elimination  was  the 
same  on  mixed  and  exclusive  milk  diets. 
They  found  no  children  in  whom  the 
albumin  excretion  corresponded  to  the 
requirements  f6r  postural  or  orthostatic 
albuminuria,  a  rather  surprising  result 
in  view  of  the  frequency  with  which 
this  condition  is  supposed  to  occur. 

Thirty-two  and  one-half  per  cent,  of 
the  children  showed  occasional  hyaline 
casts  and  cylindroids  in  the  urine.  The 
authors  do  not  consider  their  "occa- 
sional presence"  as  indicative  of  a  lesion 
of  the  kidneys,  but  rather  as  suggesting 
a  temporary  overtaxation  of  the  kid- 
neys resulting  from  variations  in  the 
habits  of  life  of  the  individuals,  which 
are  too  slight  to  be  recognized.    Eighty- 


ALBUMlNURfA    (LEVISON    AND    ERLANDSEN). 


489 


ciglit  and  scvcn-tcnths  per  cent,  of  the 
urini.'  of  these  124  chilch-cn  showed  al- 
bumin, 27.4  per  cent,  showed  serum- 
albumin  alone  and  in  combination, 
and  85.4  per  cent.,  an  albuminous  body 
precipitated  by  acetic  acid  in  the  cold. 
These  two  albumins  were  nearly  always 
present  in  very  slight  traces,  occasion- 
ally in  slight  traces,  and  rarely  in  traces. 
In  38  children  the  twenty-four-hour 
specimens  showed  nucleoalbumin  in 
all  but  1,  and  in  this  case  samples 
examined  over  prolonged  periods  of 
time  showed  nucleoalbumin  frequently. 
In  these  38  children,  the  percentage 
of  serum-albumin  was  very  much 
larger  (42.1  per  cent.)  than  in  the 
total  number  of  cases  examined.  The 
authors  believe,  therefore,  that  it  is 
possible  to  demonstrate  in  the  urine  of 
every  presumably  h^^lthy  child  traces 
of  an  albuminous  body  precipitated  by 
acetic  acid.  Consequently,  this  sub- 
stance must  be  regarded  as  an  exceed- 
ingly common,  if  not  constant  manifes- 
tation in  the  urine  of  children  under 
14  years  of  age,  and  as  of  no  clinical 
significance.  The  writers  do  not  believe 
that  serum-albumin  in  the  amounts  in 
which  it  appears  in  these  children  indi- 
cates a  diseased  condition  of  the  kid- 
neys any  more  than  does  the  presence 
of  occasional  hyaline  casts  and  cylin- 
droids,  and  that  its  etiology  may  be 
considered  the  same  as  that  given  for 
these  former  elements.  Hamill  and 
Blackfan  (Amer.  Jour,  of  Dis.  of 
Children,  Feb.,  1911;  Jour.  Amer.  Med. 
Assoc,  Mar.  4,  1911). 

From  a  pathological  point  of  view  the 
causes  of  albuminuria  may  be  divided 
into  three  groups:  1.  Disturbances  of 
circulation.  2.  Changes  of  the  tubular 
epithelial  cells  or  of  the  walls  of  the 
blood-vessels  o"  the  kidney.  3.  Changes 
in  the  composition  of  the  blood. 

1.  All  disorders  of  circulation  capa- 
ble of  causing  a  venous  renal  congestion 
will  increase  the  blood-pressure  in  the 
capillaries  of  the  kidney,  and  thus  give 
rise  to  a  transudation  of  albuminous 
liquid;    when    the    congestion    is   very 


great  the  urinary  tubules  may  even  be 
compressed  and  the  escape  of  the  urine 
rendered  difficult.  When  this  is  the 
case  and  when,  also,  the  supply  of. 
arterial  blood  is  diminished,  the  tubular 
epithelium  will  be  damaged,  and  the 
first  result  of  all  this  is  albuminuria. 
It  is  very  improbable  that  arterial  con- 
gestion ever  produces  albuminuria,  al- 
though the  experiments  of  Munk  and 
Senator  tend  to  prove  the  contrary. 
Leube  found  in  the  early  stages  of 
aortic  insufficiency,  not  accompanied  by 
cyanosis,  edema,  etc.,  a  slight  albumi- 
nuria. Pathological  examination  of  the 
kidneys  showed  the  walls  of  arteries 
and  capillaries  much  thickened.  He 
makes  these  changes  and  their  conse- 
quences responsible  for  the  malnutri- 
tion of  the  kidney  and  its  result : 
albuminuria. 

A  complicating  parenchymatous  ne- 
phritis-may exist,  as  where  the  endo- 
carditis is  caused  by  diphtheria.  The 
nephritis  is  generally  amenable  to  treat- 
ment, while  endocarditis  persists.  There 
may  be  a  general  atheroma,  which  also 
involves  the  renal  vessels,  leading  to 
arteriosclerotic  kidney.  This  is  espe- 
cially common  with  aortic  insufficiency. 
When  the  energy  of  the  heart  sinks  and 
the  cardiac  muscle  undergoes  fatty  de- 
generation, stasis,  followed  by  cyanotic 
induration,  is  found  in  all  the  organs. 
This  occurs  only  in  the  later  stages  of 
aortic  insufficiency.  Besides  this  there 
is,  however,  another  form  of  albumi- 
nuria, characteristic  for  the  early  stages 
of  aortic  insufficiency  and  not  accom- 
panied by  cyanosis,  edema,  etc.  The 
urine  is  not  diminished  in  amount,  the 
specific  gravity  is  relatively  low,  and 
the  amount  of  albumin,  hyaline  and 
granular  casts  very  slight.  Patholog- 
ical examination  of  a  few  kidneys  of 
this  kind  shows  that  the  marked  varia- 
tions in  pressure  are  responsible  for 
certain  anatomical  changes.  The  walls 
of  the  arteries  and  capillaries  are  found 
much  thickened ;  so  that  the  amount  of 
blood  carried  to  the  kidneys  must  nee- 


490 


ALBUMINURIA    (LEVISON    AND    ERLANDSEN). 


essarily  be  less  than  normal.  The  liver 
and  spleen  show  similar  lesions,  but 
never  the  lungs.  V.  Leube  (Miinch. 
med.  Woch.,  July  28,  1903). 

2.  Changes  of  the  'tubular  epitheha 
and  the  walls  of  blood-vessels  of  the 
kidneys  may,  as  already  stated,  be  due 
to  disorders  of  circulation,  but  they  may 
also  be  caused  by  different  poisons  and 
toxins.  When  albuminuria  is  chiefly 
caused  by  degeneration  of  the  tubular 
epithelia,  their  protoplasm  dissolves  in 
the  urine,  and  nucleoalbumin  in  great 
quantity  is  contained  in  it,  combined 
with  serum-albumin  and  globulin. 

Menge  and  Schreiber  noted  albumi- 
nuria in  several  cases  in  which  the 
kidney  had  been  palpated  bimanually, 
as  a  result  of  the  circulatory  changes 
produced  during  the  examination.  This 
procedure  has  been  used  by  Schreiber 
in  the  diagnosis  of  doubtful  cases  of 
floating  kidney. 

Albuminuria  follow^ing  renal  palpa- 
tion. Renal  hematuria  with  albuminu- 
ria noted  in  several  cases  in  which  the 
kidney  had  been  examined  bimanually 
and  in  which  no  albumin  had  been  pres- 
ent in  the  urine  before  examination. 
The  pressure  to  which  the  kidney  is 
exposed  causes  circulatory  changes 
which  permit  of  the  transudation  of 
serum  from  the  renal  capillaries.  C. 
Menge  (Miinch.  med.  Woch.,  June  5, 
1900). 

If  a  floating  kidney  be  palpated  in 
the  usual  manner,  albumin  will  almost 
always  appear  in  the  urine,  even  where 
only  a  small  portion  of  the  kidney  can 
be  grasped  between  the  fingers.  The 
color  of  the  urine  voided  after  palpa- 
tion is  generally  somewhat  paler,  and 
microscopical  examination  shows  an 
abundance  of  epithelial  cells  from  the 
pelvis,  ureter,  and  bladder,  cylindroids, 
red  and  white  blood-cells,  but  hardly 
ever  casts. 

The  albuminuria  is  very  probably 
caused  by  the  passage  of  serum  from 
the  capillaries  into  the  tubules.  Prob- 
ably    some     lymph     also     reaches     the 


latter,  since  there  frequently  is  no  rela- 
tion between  the  degree  of  pressure 
exerted  and  the  amount  of  albumin. 
The  observation  is  of  great  clinical 
value,  since  a  doubtful  organ  in  the 
abdomen  may  be  safely  diagnosed  as 
kidney,  if  albuminuria  follows  after 
palpation.  J.  Schreiber  (Zeit.  f.  klin. 
Med.,  Bd.  Iv). 

Albuminuria  may  be  discovered  at 
one  examination  and  not  at  the  next, 
even  the  following  day,  i.e.,  "fugal  al- 
buminuria," and  may  lead  to  errors  in 
diagnosis.  It  is  evidently  the  result  of 
some  interference  with  the  circulation 
and  may  be  encountered  as  a  direct 
consequence  of  palpation  of  the  abdo- 
men. It  occurs  only  when  the  epigas- 
trium and  mesogastrium  are  palpated, 
thus  showing  that  the  aorta  above  the 
renal  arteries  feels  the  effect  of  the 
palpating  fingers.  J.  Schreiber  (Med. 
Klinik,  Apr.  4,  1909). 

3.  When  the  composition  of  the 
blood  is  altered,  the  urine  often  becomes 
albuminous.  This  can  be  proved  ex- 
perimentally by  injecting  egg-albumin, 
soluble  casein,  hemoglobin,  etc.,  into 
the  veins  of  animals;  the  quantity  of 
albumin  excreted  after  the  injection 
will  generally  exceed  the  quantity  in- 
jected. Similar  results  may  be  obtained 
by  the  injection  of  peptone  and  propep- 
tone,  whereas  the  albuminates  are  gen- 
erally inoffensive.  Ingestion  of  a  very 
large  quantity  of  egg-albumin  is  liable 
to  provoke  albuminuria. 

Semmola  has  tried  to  prove  that  albu- 
minuria is  always  caused  by  changes  of 
the  blood  characterized  by  abnormal 
diffusibility  of  its  proteids,  and,  in  his 
opinion,  the  pathological  changes  in  the 
kidneys  are  consecutive  to  the  albumi- 
nuria. Though  his  theory  is  not  gener- 
ally accepted,  Rosenbach  has  adopted  it 
for  the  albuminuria  which  is  not  caused 
by  nephritis,  and  regards  it  in  such  cases 
as  a  salutary  and  regulating  process. 

In  most  clinical  cases  different  causes 


ALBUMINURIA    (LEVISON    AND    ERLANDSEN). 


491 


are  simultaneously  active,  and  it  is 
generally  very  difficult  to  determine 
which  is  the  preponderating  etiological 
factor.  L,  Williams  ascribes  the  ma- 
jority of  cases  of  albuminuria  either  to 
altered  blood  states  or  to  failure  in  the 
normal  vasomotor  mechanism. 

The  majority  of  the  cases  arc  due  to 
either  altered  blood  states  or  to  failure 
in  the  normal  vasomotor  mechanism. 
This  failure  may'  manifest  itself  in  one 
or  two  directions.  In  the  first,  chiefly 
by  some  means  so  far  undiscovered,  the 
blood-pressure  in  the  splanchnic  area 
arises  and  is  maintained  at  a  suffi- 
ciently high  level  to  induce  a  renal 
plethora  and  consequent  albuminuria. 
Of  such  are  the  cases  of  hyperpiesis, 
as  in  the  instance  quoted.  In  the  sec- 
ond place,  owing  to  a  local  or  general 
vasodilatation,  the  blood-pressure  in  the 
splanchnic  area  falls  to  the  point  at 
which  a  renal  stasis  is  induced.  Of 
such  are  the  cases  of  cyclical,  postural, 
and  athletic  albuminuria,  of  which  also 
instances  are  cited,  cases  which,  for  the 
most  part,  occur  in  young  adults  in 
whom  the  vasomotor  response  is  either 
undeveloped  or  for  some  reason  is  in- 
adequate. Having  regard'  to  these 
facts,  the  writer  ventures  once  more  to 
insist  not  only  that,  of  itself,  albumi- 
nuria affords  no  evidence  of  renal  dis- 
ease, but  that,  of  itself,  it  does  not 
present  even  a  reasonable  suspicion  of 
the  existence  of  such  disease  any  more 
than,  of  itself,  dyspnea  presents  a  rea- 
sonable suspicion  of  cardiac  disease.  L. 
Williams    (Clin.   Jour.,  Apr,    1908). 

It  is,  nevertheless,  true  that  traces  of 
albumin,  and  even  a  rather  considerable 
amount  of  it,  may  be  found  in  the  urine 
of  persons  otherwise  healthy  and  pre- 
senting no  symptoms  of  disease  of  the 
kidneys  or  of  the  organs  of  circulation. 

Many  clinicians,  therefore,  admit 
that  albuminuria  may  be  regarded,  in 
some  cases,  as  physiological ;  this  is, 
however,  contested  by  many. 

Case  in  which  for  over  twenty  years 
the    patient    had    been    passing    large 


quantities  of  albumin  in  the  urine,  3 
grams  per  liter.  Microscopic  examina- 
tion revealed  no  casts  or  corpuscles, 
and  there  was  nothing  to  suggest  renal 
trouble.  The  heart  was  normal  in  size, 
the  sounds  were  normal,  blood-pressure 
was  in  the  limits  of  the  normal,  and 
there  was  little  or  no  arterial  thicken- 
ing. The  patient  has  maintained  his 
usual  high  standard  of  health,  and,  al- 
though he  had  always  been  thin  and 
spare,  he  is  very  tough.  The  most  re- 
markable feature  of  the  case,  however, 
is  that  all  the  members  of  the  patient's 
family  exhibit  the  same  peculiarity. 
They  are  all  perfectly  well,  and,  con- 
sidering the  age  the  parents  have  at- 
tained (87  and  78  respectively),  such  a 
case  as  this  should  have  an  important 
bearing  on  the  question  of  rejection  or 
"loading"  of  candidates  for  life  insur- 
ance. Fergusson  (Brit.  Med.  Jour., 
Mar.   19,  1910). 

Virchow  described  a  physiological 
albuminuria  in  infants,  occurring  in 
the  first  days  of  life,  and  explained 
it  by  the  sudden  changes  of  circula- 
tion taking  place  immediately  after 
delivery. 

Flensburg  and  Sjoquist  have  shown 
that  albuminuria  regularly  occurs  in 
the  first  days  of  life,  and  that  the 
urine  also  contains  an  extraordinary 
quantity  of  uric  acid  crystals ;  prob- 
ably the  albuminuria  is  then  due  to 
the  irritation  of  the  kidneys  caused 
by  these  crystals.  Ebstein  and 
Nicolaier  have  shown  experimentally 
that  when  the  kidneys  are  forced  to 
excrete  a  surplus  of  uric  acid  which 
cannot  be  dissolved,  but  goes  to  the 
bottorn  in  the  form  of  crystals,  the 
urine  commonly  contains  albumin 
and  sometimes  even  blood. 

Gull  found  a  certain  -form,  of  ph3^sio- 
logical  albuminuria  in  adolescents 
about  the  age  of  puberty,  especially 
in  weak  and  pale  individuals.  Other 
authors,  among  whom  is  Ouain,  have 


492 


ALBUMINURIA    (LEVISOX    AXD    ERLAXDSEN). 


noticed  that  this  condition  is  quite 
frequently  associated  with  masturba- 
tion. 

Lommel  found  that  19  per  cent,  of 
young  men  (14  to  18  years  oldj  suf- 
fered from  albuminuria. without  hav- 
ing nephritis.  The  albuminuria  had 
an  intermittent  character  and  w'as 
orthostatic  in  type. 

A  large  percentage  of  boys  from 
14  to  18  years  of  age  suffer  from  albu- 
minuria without  having  nephritis.  Re- 
peated examination  of  over  500  young 
employes  of  a  large  factory  showed 
albumin  in  no  less  than  19  per  cent.  In 
most  cases  only  traces  could  be  detected, 
though  in  a  few  the  amount  exceeded 
1  pro  mille.  The  greater  part  of  the 
albumin  seemed  to  consist  of  lobulin, 
as  in  acute  nephritis,  indicating  the 
presence  of  wide  meshes  in  the  filter- 
ing apparatus  of  the  kidney.  The  cause 
of  the  albuminuria,  which  generally  had 
an  intermittent  character  and  was  ortho- 
static in  type,  was  to  be  found  in  an 
impoverished  condition  of  the  blood, 
together  with  a  mild  degree  of  cardiac 
insufficiency  and  tendency  to  stasis,  such 
as  is  liable  to  occur  during  puberty 
where  the  rapid  growth  of  the  body  is 
out  of  proportion  to  the  functional 
powers  of  the  internal  organs.  In  ac- 
cord with  this,  dilatation  of  the  heart, 
tension  of  the  arteries,  and  accentuation 
of  the  second  aortic  sound  were  fre- 
quently noted.  F.  Lommel  (Deut. 
Archiv  f.  klin.  Med.,  Bd.  Ixxviii,  Nu. 
5  u.  6,   1903 J. 

Dunhall  and  Patterson  and  Collier 
found  albuminuria  (0.2  to  15  per 
cent.j  after  severe  exercise  (such  as 
rowing  and  running  in  races j  also  in 
healthy  subjects. 

Several  instances  in  healthy  subjects 
in  which  albumin  was  found  in  varying 
amounts  after  severe  exercise  (0.02  to 
0.15  per  cent.).  The  writers  also  dis- 
covered incidentally  that  in  different 
urines  the  sensitiveness  of  boiling  and 
ferrocyanide  of  potassium  with  acetic 
acid,  as  tests  for  proteid,  varied  consid- 
erably.    S.  P.  Dunhall  and  S.  W.  Pat- 


terson    (Inter.    Med.    Jour.,    July    20, 
1902;. 

As  examiner  of  students  at  Oxford 
University,  the  writer  has,  during  the 
past,  been  in  the  habit  of  advising  all 
m.en  whose  urine  showed  the  presence 
of  albumin  after  exercise  to  give  up 
all  competitions  involving  great  muscu- 
lar strain,  such  as  rowing  and  running 
in  races.  He  found  that  if  albumin 
was  present  during  the  student's  first 
year  at  the  university  it  continued 
throughout  his  career  there.  During 
1906,  however,  he  made  systematic  ex- 
aminations of  the  various  men  in  train- 
ing for  boat-racing,  and  found  that, 
without  exception,  every  man  who 
rowed  over  the  full  course  passed  albu- 
min in  his  urine,  and  at  least  one-half 
passed  a  considerable  quantity.  The 
same  thing  was  true  of  the  running 
men.  So  that  just  as  evidence  of  hyper- 
trophy of  the  left  ventricle  of  the  heart, 
and  emphysema  of  the  lungs  may  be 
expected  in  men  indulging  in  violent 
athletics,  so  may  the  presence  of  a 
definite  amount  of  albumin  in  the  urine 
for  a  few  hours  after  such  exercises 
be  looked  for.  The  writer,  therefore, 
no  longer  holds  that  such  men  should 
be  advised  to  give  up  all  hard  athletic 
competitions,  nor  should  insurance  com- 
panies continue  to  refuse  to  consider 
the  acceptance  of  the  lives  of  such  men. 
Collier  (Brit.  Med.  Jour.,  Jan.  5,  1907). 

PHYSIOLOGICAL  CYCLICAL, 
ORTHOSTATIC,AND  ORTHOTIC 

ALBUMINURIA.— The  question  of 
physiological  albuminuria  in  adults 
has  been  much  discussed  during  the 
past  few  years  and  has  particularly 
engaged  the  interest  of  the  medical 
men  employed  in  insurance  work. 

It  is  characteristic  of  physiological 
albuminuria  that  the  quantity  of  albu- 
min is  generally  small  and  that  the 
excretion  is,  in  most  cases,  intermit- 
tent, or  cyclical.  Leube,  Pa\'y,  Fiir- 
bringer,  Klemperer,  and  many  other 
authors  have  studied  this  condition. 

Pavy  introduced  the  denomination 
"cyclical   albuminuria"   for  the   cases 


ALBUMINURIA    (LEVISON    AND    ERLANDSEN). 


493 


in  which  the  allniniinuria  ceases  and 
returns  at  regular  intervals. 

Stirling  ascribes  cyclical  albumi- 
nuria to  a  sudden  shock  from  the 
blood-pressure  upon  assuming  the 
upright  position  on  arising,  but 
Rudolph  showed  that  albumin  also 
appeared  in  the  urine  when  the  up- 
right position  was  assumed  very 
slowly. 

.  Pavy  likewise  insists  upon  posture  as 
the  invariable  cause  of  cyclical,  or  in- 
termittent, albuminuria,  the  excretion 
ceasing  when  the  subject  is  in  the  re- 
cumbent position  and  going  on  only 
when  he  is  walking  or  standing.  The 
cycles  are  commonh-  completed  within 
the  day,  but  in  a  case  narrated  by  Klem- 
perer  there  were  two  cycles^  the  maxi- 
mum of  albuminuria  taking  place  in  the 
forenoon  and  afternoon. 

Hauser  concludes  that  these  cases 
can  always  be  traced  back  to  an  uncured 
nephritis  or  to  some  acute  infection 
(notably  scarlatina),  and  puts  no  cre- 
dence in  a  functional  disorder.  In  other 
words,  he  always  considers  cyclical  al- 
buminuria as  the  expression  of  some 
pathological  factor. 

The  writer  records  a  prolonged  study 
of  14  cases  of  cyclical  albuminuria,  and 
concludes  that  these  cases  can  invari- 
ably be  traced  to  an  uncured  nephritis, 
or  to  some  of  the  acute  infectious  dis- 
eases, especially  scarlatina.  The  author 
does  not  believe  that  a  functional  disor- 
der exists  in  these  cases,  but  refers  the 
appearance  of  albumin  to  excessive 
muscular  use  which  affects  the  epithe- 
lium of  the  vessels  of  the  glomeruli  by 
an  increase  in  toxins  or  in  metabolic 
products.  Hauser  (Berl.  klin.  Woch., 
Dec.  14,  1903). 

Case  of  a  young  man,  21  j^ears  of 
age,  who  had  suffered  for  eight  j^ears 
from  intermittent  albuminuria  that  ap- 
peared as  a  sequela  to  an  attack  of 
nephritis  caused  by  scarlet  fever.  Eich- 
horst   (Med.  Klinik,  April  18,  1909). 


Oswald  attributes  all  forms  of  albu- 
minuria of  adolescence  to  irritation  of 
the  renal  epithelium. 

There  is  no  difference  between  the 
albuminuria  of  puberty  and  the  so- 
called  physiological  albuminuria  of 
adult  "life:  between  orthostatic  albu- 
minuria in  a  man  and  the  puberal  albu- 
minuria of  a  bo3^  The  writer  considers 
that  both  are  due  to  irritation  of  the 
renal  epithelium.  A.  Oswald  (Miinch. 
med.  Woch.,  1904). 

Aloritz  ascribes  cyclical  albuminuria 
to  some  insufBciency  of  the  circulatory 
apparatus,  having  observed  that  the  in- 
creased blood-pressure  which  normally 
occurs  after  moderate  exercise  is  fol- 
lowed by  abnormally  low  pressure  in 
individuals  that  are  subject  to  C3xlical 
albuminuria. 

Cyclical  albuminuria  is  due  to  some 
insufliciency  of  the  circulatory  appa- 
ratus, for  the  writer  noticed  that  the 
increased  blood-pressure  which  nor- 
mally occurs  after  exercise  of  a  mod- 
erate degree  was  followed  by  abnor- 
mally low  pressure  in  those  persons 
who  were  inclined  to  display  a  tendency 
toward  c\-clical  albuminuria.  He  made 
some  practical  tests  in  two  patients  of 
this  type  bj-  requiring  them  to  lie  down 
and  then  artificialh-  inducing  a  disturb- 
ance of  respiration  by  calling  on  them 
for  straining  efforts  for  ten  or  fifteen 
minutes,  similar  to  those  at  stool.  This 
was  invariably  followed  by  the  appear- 
ance of  albumin  in  the  urine,  although 
none  had  been  present  before.  P. 
Moritz  (Deut.  med.  Woch.,  Nu.  Zl, 
1903). 

The  diagnosis  of  physiological  albu- 
minuria ought  not  to  be  made  except  in 
cases  when  persons  presenting"^  no  other 
symptom  of  disease  excrete,  constantly 
or  intermittently,  a  urine  containing  a 
scanty  quantity  of  albumin,  but  no 
morphotic  elements  and  especially  no 
casts.  The  centrifugal  apparatus,  now 
in  general  use,  will  certainly  contribute 
to  restrain  the  number  of  these  cases. 


494 


ALBUMINURIA    (LEVISOxN    AND    ERLANDSEN). 


The    urine    should    be    obtained    by 
catheterism  in  all  doubtful  cases. 

The  prognosis  is  generally  considered 
good  (Broadbent,  Beck,  Dukes,  Ties- 
sier,  Posner).  Nevertheless  it  is  still 
justifiable  for  life-insurance  examiners 
to  be  cautious  in  accepting  persons 
suffering  from  albuminuria. 

Orthostatic  albuminuria  is  one  of  the 
functional  albuminurias,  and  requires 
the  erect  posture  for  its  appearance.  It 
appears  in  young  persons  who  are 
otherwise  healthy,  is  not  influenced  by 
fatigue,  habit  to  milk  diet,  and  is  not 
accompanied  by  any  of  the  functional 
conditions  associated  with  Bright's  dis- 
ease. The  discovery  is  purely  acci- 
dental, and  depends  upon  methodical 
examination  of  the  urine.  Standing 
immobile  will  cause  it  to  appear,  and 
lying  down  to  disappear.  The  albumin 
may  persist  while  the  patient  is  walk- 
ing, but  walking  alone  does  not  produce 
it.  No  functional  disturbances  in  the 
other  organs  can  explain  this  form  of 
albuminuria.  Orthostatic  albuminuria 
occurs  equally  in  both  sexes,  in  neuro- 
pathic and  slightly  anemic  adolescents, 
presenting  a  nervous  or  diathetic  hered- 
ity, and  is  always  associated .  with  an 
appreciable  disturbance  of  the  vaso- 
motor system.  It  seems  to  be  due  to 
fluctuating  congestion  of  the  kidney,  a 
vasomotor  disturbance  of  the  renal  cir- 
culation comparable  to  cyanosis  of  the 
extremities  produced  by  the  same  cause. 
H.  G.  Beck  (Amer.  Jour.  Med.  Sci., 
Sept.,  1903). 

There  is  an  affection  which  may  be 
called  postural  albuminuria.  Its  char- 
acteristic feature  is  albuminuria  on  ris- 
ing from  bed  in  the  morning,  usually 
passing  off  in  the  course  of  the  day. 
It  is  most  common  in  boys  and  young 
men,  especially  those  who  are  studying 
hard.  It  is  not  due  to  food,  does  not 
appear  if  the  patient  remains  in  bed  to 
breakfast,  and  disappears  quickly  on 
lying  flown.  It  is  obviously  in  relation 
with  the  erect  posture  after  a  night's 
rest  in  bed,  and  with  imperfect  cardio- 
vascular adjustment  to  the  changed 
hydrostatic  conditions.     The  amount  of 


albumin  may  be  very  small,  but  it  is 
usually  very  considerable.  Its  recog- 
nition is  important,  as  the  treatment  re- 
quired is  the  exact  reverse  of  the  usual 
milk  diet  and  protection  from  cold  and 
fatigue. 

The  most  common  antecedent  is 
a  neurotic  family  history  and  cardio- 
vascular instability.  The  pulse  varies 
greatly  in  frequency  and  is  greatly 
influenced  by  changes  of  position.  The 
violent  cardiac  impulse  is  due  to  for- 
cible action  of  the  right  ventricle,  the 
apex  beat  being  weak,  and  the  second 
sound  is  reduplicated  on  lying  down. 
The  prognosis  is  favorable,  all  the  treat- 
ment usually  required  being  good,  simple 
food ;  fresh  air,  and  vigorous  exercise. 
Tonics  may  be  useful  and  constipation 
should  be  corrected.  If  these  cases  are 
treated  for  renal  disease  they  usually 
go  from  bad  to  worse,  and  become  con- 
firmed nervous  valetudinarians.  Broad- 
bent    (Brit.   Med.  Jour.,  Jan.  2,   1904). 

When  the  albuminuria  of  adolescents 
is  recognized  and  treated,  there  is  lit- 
tle likelihood  of  its  proving  the  precur- 
sor of  organic  disease  of  the  kidneys, 
even  when  its  duration  has  been  many 
years.  The  general  treatment  resolves 
itself  into  so  reasonable  a  regulation 
of  life  as  to  insure  the  highest  state 
of  vitality  during  adolescence :  Work, 
while  it  may  be  ample,  must  not  be 
excessive ;  and  work  is  always  excess- 
ive during  the  years  of  growth,  when 
sleep  is  insufficient.  The  hours  of  both 
must  be  determined  according  to  age. 
Exercise  should  be  recreation  rather 
than  physical  drill,  which,  by  the  pleas- 
urable sensations,  increases  the  tone  of 
the  whole  nervous  and  vascular  sys- 
tem, and  such  exercise  should  be  daily. 
Food  should  be  sufficient  for  the  pro- 
vision of  growth,  as  well  as  the  re- 
moval of  wear  and  tear,  bearing  in 
mind  that  the  adolescent  requires  more 
food  than  the  adult,  and  the  girl  more 
than  the  boy  on  account  of  her  greater 
rapidity  of  growth.  The  duties  of  the 
scavengers  of  the  body  should  be  so 
disciplined  as  to  be  brought  under  the 
habitual  control  of  the  will.  Natural 
action  should  not  be  replaced  by  the 
perpetual  stimulus  of  aperients,  for  this 


ALBUMINURIA    (LEVISON    AND    ERLyVNDSEN). 


495 


vicarious  duty  obviously  confirms  the 
intestines  in  sluggishness  of  work,  and 
tends  to  convert  a  temporary  inactivity 
into  a  permanent  abandonment  of  func- 
tion. Clement  Dukes  (Brit.  Med.  Jour., 
Oct.  7,  1905). 

It  is  a  mistake  to  diagnose  a  nephri- 
tis in  every  case  where  traces  of  albu- 
min are  excreted.  With  delicate  tests 
albumin  may  be  detected  in  almost 
every  urine,  but  larger  quantities  often 
occur  in  the  so-called  essential  albu- 
minuria, and  merely  signify  that  the 
renal  filter  has  become  less  dense  with- 
out, however,  altering  the  appearance 
or  function  to  such  an  extent  that  a 
nephritis  may  be  assumed.  If  the  his- 
tory of  such  cases  be  studied  in  detail, 
an  infectious  disease  will  often  be  dis- 
covered as  cause,  but  even  after  years 
the  amount,  appearance,  and  specific 
gravity  of  the  urine  will  remain  normal 
and  casts  are  uncommon  or  absent  alto- 
gether. The  treatment  consists  in 
proper  diet  and  mode  of  living,  since 
the  kidneys  undoubtedly  form  a  locus 
minoris  resistentice,  and  a  nephritis  may 
follow  after  the  use  of  much  alcohol, 
etc.  C.  Posner  (Zeit.  f.  klin.  Med., 
vol.  liii,  1904). 

It  is  no  longer  justifiable  for  life  in- 
surance and  other  such  examiners  to 
take  the  serious  view  hitherto  accepted 
by  most  clinicians  of  physiological  albu- 
minuria. When  it  is  found  that  the 
excretory  function  is  being  properly 
performed ;  that  the  substances  nor- 
mally gotten  rid  of  through  the  kidneys 
are  not  being  retained  in  the  organism, 
and  that  the  albumin  in  the  urine  may 
be  diminished  by  lessening  the  hydro- 
static pressure  upon  the  renal  capil- 
laries by  increasing  the  coagulability  of 
the  blood,  there  is  every  reason  to  con- 
clude that  the  kidneys  are  free  from 
organic  disease,  that  life  is  not  in  the 
least  endangered.  Instances  reported 
in  which  excellent  results  have  been 
achieved  by  the  administration  of  cal- 
cium chloride  in  doses  of  20  grains 
three  times  a  day.  Calcium  lactate  in 
the  same  dosage  is  also  useful.  Both 
increase  the  coagulability  of  the  blood. 
A.  E.  Wright  and  G.  W.  Ross  (Lancet, 
Oct.  21,  1905). 


Very  small  proportions  of  albumin 
should  not  be  taken  into  account  in  rela- 
tion to  life  insurance,  and  consequently 
the  writer  does  not  regard  as  of  much 
moment  the  efforts  to  produce  more  and 
more  delicate  tests  for  albuminuria. 
The  so-called  physiological  slight  albu- 
minuria after  excessive  exertion,  sports, 
etc.,  may  also  be  disregarded.  The 
majority  of  cases  of  orthostatic  albu- 
minuria are  also  comparatively  harm- 
less; it  is  exceptional  for  nephritis  to 
develop  later  in  these  cases.  In  ex- 
amining it  is  important  to  note  the 
absence  of  the  higher  blood-pressure 
characteristic  of  contracted  kidney; 
also  that  the  urine  is  free  from  albu- 
min during  reclining.  Fiirbringer 
(Deut.  med.  Woch.,  Nov.  25,  1909). 

Teissier  distinguishes  three  groups  of 
orthostatic  albuminuria :  The  true  or- 
thostatic albuminuria,  where  the  albu- 
min appears  very  soon  after  assuming 
the  erect  posture.  It  disappears  in  the 
recumbent  posture.  The  mixed  ortho- 
static albuminuria,  which,  more  slow  in 
its  development  (usually  not  before  ten 
and  twelve  in  the  morning),  is  found 
in  persons  with  an  earlier  acute  infec- 
tion and  believed  to  be  due  to  actual 
organic  changes  in  the  kidney.  The 
associated  orthostatic  albuminuria  is 
also  slower  in  making  its  appearance 
after  assuming  the  erect  posture  and  is 
associated  with  abnormal  conditions  of 
other  organs  (dilated  stomach,  ente- 
roptosis,  movable  kidney,  etc.). 

As  nephritis  can  be  excluded  in  the 
greatest  majority  of  cases  of  orthotic 
albuminuria  in  children,  a  milk  diet  is 
contraindicated  and  a  strengthening 
general  diet  indicated.  In  addition, 
there  should  be  physical  treatment  to 
increase  the  general  strength,  with 
special  attention  to  muscles  of  the  lum- 
bar region.  Jehle  (Miinch.  med. 
Woch.,  Jan.  7,  1908). 

Examination  of  150  girls  between  the 
ages  of  9  and  14  to  determine  the  in- 
fluence of  curvature  of  the  spine  on 
orthostatic     albuminuria.       It     showed 


496 


ALBUMINURIA    (LEVISON    AND    ERLANDSEN). 


that  curvature  of  the  spine  is  not  the 
exclusive  cause  of  orthostatic  albumi- 
nuria, although  it  is  an  important 
factor  in  many  cases  by  its  interference 
with  the  circulation  in  the  kidneys. 
Vas  (Deut.  med.  Woch.,  Aug.  26,  1909). 

Albuminuria  in  4  girls  between  12 
and  16,  nervous  and  anemic,  but  the 
albuminuria  disappeared  when  the  girls 
remained  in  bed.  There  was  nothing 
but  the  albumin  to  indicate  anything 
wrong  in  the  kidney  or  circulation. 
The  albuminuria  could  be  induced  at 
will  by  inducing  lordosis.  During  the 
years  of  most  active  growth  the  verte- 
brae are  not  supported  so  firmly  as 
later  in  life,  and  the  physiologic  curve 
of  the  spine  becomes  exaggerated  by 
the  laxness  of  the  ligaments,  etc.  Tur- 
rettini  (Revue  de  med.,  Sept.,  1909). 

There  are  two  indications  to  be  fol- 
lowed :  an  avoidance  of  lumbar  lordosis 
while  standing  or  walking,  and  eflforts 
to  strengthen  the  muscles  of  the  loins 
and  abdomen  in  order  to  correct  as 
quickly  as  possible  the  incorrect  and 
harmful  position.  Fischel  (Med.  Klin., 
May  1,  1910). 

Examination  of  346  children  between 
the  ages  of  5  and  13  for  albuminuria 
showed  that  14.5  per  cent,  189  girls  and 
157  boys,  gave  signs  of  orthostatic 
albuminuria.  There  did  not  seem  to  be 
any  more  pronounced  tendency  to 
neuropathies  among  these  children  than 
among  their  mates,  although  enlarged 
tonsils  or  chronic  pharyngitis  were 
more  frequent  among  them.  There 
was  no  trace  of  pathological  lordosis 
among  a  large  number  of  the  children, 
while  true  lordosis  was  quite  frequent 
among  children  free  from  any  tendency 
to  albuminuria.  F.  Gotzky  (Jahrbuch , 
f.  Kinderheilk,  April,  1910). 

Even  when  no  casts  can  be  found, 
albuminuria  ought  never  be  regarded 
as  absolutely  inoffensive.  Although  a 
cyclical  albuminuria  continuing  years 
may  be  compatible  with  perfect  health, 
many  authors  (Johnson,  Greenfield, 
Bull,  etc.)  are  of  the  opinion  that  it  sig- 
nifies the  first  stage  of  the  evolution  of 


granular  atrophy  of  the  kidneys.  On 
the  other  hand,  casts  may  be  found  in 
normal  urine  and  do  not  mean  nephritis. 
Tuttle,  for  example,  beheves  that  ne- 
phritis may  exist  without  albuminuria. 

The  mass  of  evidence  which  has  come 
to  us  of  late  from  the  autopsy  table 
shows  conclusively  that  chronic  nephri- 
tis exists  and  is  an  unrecognized  cause 
of  death  in  a  proportion  of  cases  far 
beyond  ordinary  belief,  and  the  com- 
parison of  carefully  kept  records  of 
cases  before  death  with  autopsy  find- 
ings shows  that  little  reliance  can  be 
placed  on  the  mere  urinary  examina- 
tion, either  positive  or  negative,  as  a 
means  of  absolute  diagnosis  or  prog- 
nosis of  Bright's  disease.  The  writer's 
own  experience  leads  him  to  believe 
that  (1)  Bright's  disease  may  exist 
without  the  ordinary  urinary  manifes- 
tations— viz.,  albumin  or  casts ;  (2) 
albumin  and  casts  may  be  found  in  the 
normal  urine  and  do  not  necessarily 
mean  Bright's  disease ;  (3)  given  a 
case  of  chronic  Bright's  disease  with 
albuminuria,  the  fact  of  its  presence,  its 
constancy,  or  its  amount  has  absolutely 
no  prognostic  significance.  C.  A.  Tuttle 
(Jour.  Amer.  Med.  Assoc,  Mar.  31, 
1900). 

Series  of  experiments  show  that  the 
albumin  present  in  nephritic  urine  is 
derived  from  the  blood  and  is  different 
from  the  specific  kidney  albumins.  L. 
Aschoff   (Lancet,  Sept.  6,  1902). 

The  albuminuria  often  found  in  par- 
turient women  (Aufrecht  saw  it  in  56 
per  cent,  of  all  cases)  must  be  regarded 
as  physiological. 

Albuminuria  occurring  during  labor 
is  a  reasonable  accompaniment  of  par- 
turition ;  the  quantity  is  greater  than 
can  be  considered  normal,  and  is  often 
the  greatest  seen  in  any  except  a 
permanent  pathological  condition.  The 
condition  requires  no  especial  and  sep- 
arate treatment,  and  cannot  be  con- 
sidered a  permanent  pathological  lesion. 
The  albuminuria  of  labor  is  differen- 
tiated from  the  other  by  the  presence 
of  labor  and  by  the  fact  that  it  ceases 


ALBUMINURIA    (LEVISON    AND    ERLANDSEN). 


497 


after  parturition.  The  more  abundant 
the  albumin,  the  more  gradual  is  its  dis- 
appearance. The  albuminuria  of  the 
puerperal  period  is  the  continuation  of 
that  of  labor,  and  is  never  a  separate 
condition.  The  Ibuminuria  of  labor  is 
most  pronounced  toward  the  end  of 
parturition,  especially  in  cases  of  diffi- 
cult or  complicated  labor.  Circum- 
stances which  do  not  tend  to  make  par- 
turition especially  difficult  have  no  in- 
fluence upon  its  albuminuria.  The  sedi- 
ment of  urine  taken  during  labor  shows 
organized  material,  including  cylin- 
droids,  so  often  seen  in  cases  of  abun- 
dant albuminuria.  These  cylindroids 
are  not  abundant,  and  are  to  be  dis- 
tinguished from  others  by  the  fact  that 
they  contain  superficial  kidney  epithe- 
lium in  abundance,  but  not  the  elements 
which  come  from  the  deeper  kidney 
structures.  Jageroos  (Archiv  f.  Gyn., 
Bd.  xci,  Hft.  1,  1910;  Amer.  Jour.  Med. 
Sci.,  Nov.,   1910). 

PATHOLOGICAL  ALBUMINU- 
RIA. —  Pathological  albuminuria  is 
found  in  pathological  changes  of  the 
blood — as  anemia,  leukemia,  pseudo- 
leukemia, scurvy,  icterus,  and  diabetes 
— even  when  the  kidneys  do  not  present 
pathological  changes. 

It  is  also  found  in  many  disorders 
of  the  nervous  system,  as  epilepsy, 
migraine,  psychosis  apoplexy,  neuras- 
thenia, and  Basedow's  disease,  etc. 
Delirium  tremens  has  also  been  men- 
tioned as  a  nervous  disease  often  com- 
plicated with  albuminuria.  H.  H. 
Schroeder  regards  excessive  eating, 
overindulgence  in  alcoholic  drinks  and 
possibly  tobacco  as  the  most  frequent 
causes  of  albuminuria. 

Transient  albuminurias  are  not  of 
serious  import  unless  they  occur  too 
frequently.  Persistent  and  even  cyclic 
albuminurias  should  cause  anxiety  on 
the  part  of  the  attending  physician,  who 
should  endeavor  to  ascertain  the  cause, 
and,  if  possible,  remove  it.  A  careful 
examination  of  these  cases  means  a 
study  of  the  twenty-four-hour  speci- 


men of  urine.  The  daily  quantity  as 
well  as  specific  gravity  and  amount  of 
urea  should  be  noted,  and  there 
should  be  an  examination  for  albumin 
and  casts.  The  blood-vessels  should 
receive  attention.  Such  observations 
might  have  to  extend  over  months  or 
even  years.  The  most  frequent 
causes  of  albuminuria  are  excessive 
eating,  overindulgence  in  alcoholic 
drinks  and  possibly  tobacco,  and  the 
gouty  diathesis.  H.  H.  Schroeder 
(Med.  Rec,  July  18,  1903). 

Although  the  kidneys  are  theoretically 
believed  to  be  healthy  in  the  diseases 
mentioned  above,  there  is  no  doubt  that 
albuminuria,  in  many  cases  of  this  class, 
is  caused  by  pathological  changes  of  the 
kidneys. 

In  all  febrile  and  especially  in  all  in- 
fectious diseases  albuminuria  is  a  very 
frequent  symptom.  It  has  been  noticed 
in  enteric  fever,  diphtheria,  variola, 
after  vaccination,  in  erysipelas,  influ- 
enza, rheumatic  fever,  pneumonia,  etc. 
In  these  cases  the  albuminuria  is  caused 
by  changes  in  the  composition  of  the 
blood,  increase  of  blood-pressure,  rise 
of  temperature,  and  finally  by  changes 
in  the  structure  of  the  kidneys,  espe- 
cially of  the  tubular  epithelial  cells 
caused  by  the  toxic  substances  excreted. 

The  presence  of  albuminuria  in 
pregnancy,  as  stated  above,  is  com- 
mon (56  per  cent.).  Casts  are  only 
found  in  about  50  per  cent,  of  these 
cases  of  simple  albuminuria.  The  so- 
called  kidney  of  pregnancy  is  to  be 
regarded  as  a  specific  toxic  nephritis 
which  tends  to  recur  in  subsequent 
pregnancies.  The  prognosis  of  it,  if 
properly  treated,  is  good. 

Albuminuria  has  been  observed  in 
diseases  of  the  intestines,  dilatation  of 
the  stomach,  ileus,  ruptures,  etc.,  and 
in  renal  venous  congestion  caused  com- 
monly by  disease  of  the  heart  or  the 
great  vessels. ' 

1—32 


498 


ALBUMINURIA    (LEVISON    AND    ERLAXDSEX). 


It  is  present  in  all  diseases  of 
the  kidneys.  Acute,  as  well  as 
chronic,  albuminuria  is  generally 
found  in  the  diffuse  forms  of  nephri- 
tis, as  well  as  in  circumscribed  renal 
diseases — such  as  infarcts,  abscesses, 
or  tumors.  After  retention  of  urine 
the  portion  of  urine  first  passed  is  fre- 
quently albuminous. 

A  large  amount  of  albumin,  without 
blood  or  pus,  may  generally  be  taken  to 
indicate  chronic  tubal  nephritis,  and  this 
can  be  confirmed  by  a  high  specific 
gravity,  by  microscopic  examination, 
and  by  the  appearance  of  the  patient. 
A  very  small  trace  in  an  elderly  or 
middle-aged  man  will  probably  indicate 
chronic  interstitial  nephritis;  confirma- 
tory evidence  can  be  found  in  the 
aspect,  the  history,  the  pulse  tension 
and  tracing,  the  outward  displacement 
of  the  cardiac  impulse,  the  accentua- 
tion of  the  systolic  apical  sound,  and 
the  accentuation  and  reduplication  of 
the  second  sound  at  the  base  of  the 
heart.  These  indications  may  be  fur- 
ther supported  in  some  cases  by  the 
pale  color  and  low  specific  gravity  of  the 
urine;  less  frequently  information  may 
be  gathered  from  the  presence  of  casts 
and  from  their  predominant  characteris- 
tics. The  absence  of  casts  is  not,  how- 
ever, to  be  regarded  as  an  indication 
that  the  case  is  not  one  of  chronic  inter- 
stitial nephritis.  In  a  young  man  a 
mere  trace  of  albumin  may  be  the  only 
evidence  of  a  functional  albuminuria, 
and  the  diagnosis  must  then  rest  upon 
negative  evidence  to  a  large  extent, 
one  of  the  most  important  factors  be- 
ing the  relatively  high  specific  gravity, 
unless  this  has  been  influenced  by 
nervousness  or  by  the  recent  consump- 
tion of  a  large  quantity  of  liquid.  With 
the  same  limitations  the  deep  color  of 
the  urine  will  lend  confirmatory  evi- 
dence. 

There  are  so  many  causes  for  great 
variations  in  the  condition  of  the  urine 
that  stress  cannot  be  laid  upon  the 
amount  of  albumin  without  paying  due 
regard  to  most  of  the  changes  which 
have  been  touched  upon  by  the  writer. 


After  all,  albumin  is  merely  an  indi- 
cation of  an  abnormal  condition ;  it  is 
not  a  disease.  Therefore,  as  with  every 
other  symptom,  by  itself,  it  affords  no 
reasonable  ground  for  a  diagnosis. 
Numerous  other  signs  and  symptoms 
must  be  carefully  weighed,  perhaps  at 
short  intervals,  before  it  is  justifiable 
to  express  more  than  a  provisional 
diagnosis.  Nestor  Tirard  (Lancet,  Oct. 
9,   1909). 

Albumin  is  found  in  many  diseases 
of  the  ureter,  the  bladder,  the  pros- 
tate and  urethra.  Ballenger  speaks 
of  prostatic  albuminuria  as  a  name 
for  an  albuminous  secretion  from  an 
hyperemic  or  inflamed  prostate.  This 
prostatorrhea  is  constant  by  chronic 
prostatitis  and  often  increases  regu- 
larly every  ten  to  thirty  days.  It 
should  not  be  taken  for  a  true  albu- 
minuria. 

In  making  insurance  examinations  as 
well  as  in  the  diagnosis  of  obscure 
forms  of  albuminuria,  this  possibility 
should  be  eliminated  with  the  other 
sources  of  contamination  before  reach- 
ing a  positive  conclusion  as  to  the  sig- 
nificance of  albumin.  The  periodic  in- 
crease in  the  prostatic  discharge,  along 
with  the  striking  similarity  between  the 
symptoms  of  intermittent,  postural, 
orthostatic,  and  cyclical  albuminuria  and 
prostatorrhea,  makes  the  possibility  of 
.  mistakes  in  the  diagnosis  extremely 
likely  when  this  fluid  flows  back  into 
the  bladder,  and  does  not  appear  at 
the  meatus.  This  regular  increase 
every  ten  to  thirty  days  and  the  anal- 
ogy between  the  uterus  and  the  pros- 
tate suggest  a  relation  between  the 
causes  of  this  condition  and  menstrua- 
tion. E.  G.  Ballenger  (N.  Y.  Med. 
Jour.,  Feb.  24,  1906). 

The  writer  means  by  alimentary  al- 
buminuria the  passage  of  native  food 
albumin,  as  such,  unchanged  from  the 
alimentary  tract  into  the  urine.  One 
should  learn  to  recognize  the  existence 
of  a  distinct  and  well-characterized 
form  of  albummuria  of  rather  favorable 
prognosis  that  is  not  due  to  a  nephritis 


ALBUMINURIA    (LEVISON    AND    ERLANDSEN). 


499 


of  toxic  or  infectious  origin,  to  cir- 
culatory disturbances  in  the  kidneys,  to 
general  cardiorenal  disease  (Rright's 
disease  in  the  modern  sense),  but  is 
due  primarily  to  digestive  disorders  of 
a  certain  type.  We  are  dealing  here 
with  an  exclusively  enterogenous  al- 
buminuria in  the  interpretation  of 
which  the  renal  idea  proper  should  be 
largely  relegated  to  the  background  and 
in  which  treatment  should  not,  as  in 
Bright's  disease,  be  directed  chiefly 
against  disturbances  about  the  general 
metabolism  and  the  cardiovascular  ap- 
paratus, but  against  a  well-characterized 
perversion  of  the  gastrointestinal  and 
hepatic  ductions.  Croftan  (Archives 
of  Diagnosis,  Oct.,  1908). 

Merk  found  that  many  affections 
of  the  skin,  eczema,  pruritus,  urti- 
caria, erythema,  and  furunculosis,  are 
intimately  associated  with  albumi- 
nuria. Gunzberger  noted  albumi- 
nuria during  a  severe  attack  of  acute 
urticaria.  Nicolas  and  Jambon  and 
Boas  hold  that  albuminuria  is  a  fre- 
quent accompaniment  of  scabies,  but 
it  is  not  satisfactorily  settled  how  it 
produces  this  phenomenon. 

Albuminuria  is  a  frequent  accom- 
paniment of  scabies.  The  connection 
between  scabies  and  albuminuria  is  not 
merely  that  of  coincidence;  it  is  not 
to  be  explained  by  the  assumption  that 
the  subjects  were  already  affected  with 
renal  disease  and  the  itch  was  simply 
a  casual  acquisition,  though  persons 
who  have  been  subjected  to  the  ordi- 
nary causes  of  nephritis  are  more  likely 
than  others  to  be  attacked  with  it  in 
the  course  of  scabies.  The  cutaneous 
irritation  may  of  itself  give  rise  to  the 
kidney  trouble  through  the  mediation  of 
the  nervous  system,  but  the  manner  in 
which  scabies  gives  rise  to  albuminuria 
is  by  no  means  satisfactorily  settled. 
J.  Nicolas  and  A.  Jambon  (Annales  de 
dermat.  et  de  syphil.,  Feb.,  1908). 

Lancereaux  observed  frequently  al- 
buminuria in  his  cases  of  gouty,  her- 
petic diabetes,  but  never  noted  it  in 


his  40  cases  of  pancreatic  diabetes. 
Glycosuria  alone  does  not  entail  al- 
buminuria. When  it  occurs  it  may 
•be  connected  with  arteriosclerosis, 
with  subsequent  lesions  of  the  kid- 
neys and  heart,  or  be  due  to  some 
intercurrent  affection,  tuberculosis  in 
particular. 

Certain  remedies  may  also  give  rise 
to  albuminuria. 

The  prognosis  and  treatment  of 
albuminuria,  therefore,  depend  en- 
tirely on  the  origin  and  causes  of  it, 
and  the  reader  is  referred  to  the 
various  diseases  in  which  it  occurs  as 
a  symptom. 

Investigations  showing  the  existence 
in  many  cases  of  a  direct  relationship 
between  the  acid  content  of  the  urine 
and  the  amount  of  albumin  and  tube 
casts  present.  In  the  first  case  of  al- 
buminuria, the  administration  of  phos- 
phoric acid  was  found  to  cause  an  im- 
mediate increase  in  the  albuminuria. 
In  other  words,  with  an  increased 
acidity  of  the  urine,  there  was  a  corre- 
sponding increase  in  the  amount  of  al- 
bumin. On  the  administration,  how- 
ever, of  alkalies  in  place  of  the  acid, 
the  albumin  and  tube  casts  diminished 
and  finally  disappeared.  All  the  cases 
which  were  examined  showed  that,  with 
increased  acidity,  there  was  increased 
albuminuria,  and,  corresponding  with  a 
diminution  in  acid,  there  is  a  diminution 
in  the  albuminurii.  At  the  same  time, 
in  all  cases  of  advanced  grave  kidney 
trouble,  and  especially  in  uremic  pa- 
tients, the  relationship  to  acidity  cannot 
always  be  demonstrated.  The  writer 
goes  on  to  show  that  not  only  is  the 
albuminuria  lessened  by  alkali  adminis- 
tration, but  the  functioning  of  the  kid- 
ney is  greatly  improved  and  the  very 
important  excretion  of  chlorides  is  ac- 
celerated. The  best  mode  of  adminis- 
tration of  the  alkali  is  in  the  form  of 
the  ordinary  sod.  bicarb.,  which  must 
sometimes  be  given  in  large  doses.  V. 
Hoesslin  (Miinch.  med.  Woch.,  Aug. 
17,  1909). 


500 


ALBUMINURIA    (LEVISON    AND    ERLANDSEN). 


TESTS. — By  means  of  the  tests 
commonly  employed  the  presence  of 
albumin  in  the  urine  is  revealed,  but 
no  attempt  is  made  to  discern  be- 
tween the  different  proteids ;  the  dif- 
ferential diagnosis  between  the  serum- 
albumin,  globulin,  etc.,  will  be  given 
later  on. 

The  sample  of  urine  to  be  examined 
must  be  very  limpid  without  deposits 
of  any  kind ;  if  this  be  not  the  case, 
the  urine  should  be  filtered  previous 
to  the  examination,  because  a  slight 
cloud  of  coagulated  albumin  will  only 
be  discernible  when  the  fluid  is  very 
clear  before  the  reagent  has  been 
added.  When  the  urine  contains 
many  bacteria,  even  repeated  filtra- 
tion will  be  insufficient  to  make  it 
clear;  this  can  then  be  done,  however, 
by  addition  of  a  solution  of  sulphate 
of  magnesia  and  of  carbonate  of  soda. 
By  shaking  the  mixture  a  precipitate 
of  carbonate  of  magnesia  is  formed, 
and  when  this  is  removed  by  filtra- 
tion the  filtrate  will  be  perfectly 
clear.  In  many  cases  a  few  drops  of 
caustic  soda  will  clear  the  urine,  but 
urine  treated  in  this  manner  will  not 
give  a  precipitate  of  albumin  by  boil- 
ing, while  the  test  of  Heller  is  practi- 
cable also  in  this  case. 

Test  by  Boiling. — A  few  c.c.  of 
urine  are  heated  to  the  boiling  point 
and  some  (5  to  10)  drops  of  nitric 
acid  added.  When  the  urine  is  acid 
the  albumin  will  ordinarily  coagulate 
by  boiling  alone  and  precipitate  as 
a  whitish  powder  or  in  small  flakes. 
The  nitric  acid  is  nevertheless  in  all 
cases  to  be  added,  as  well  in  order 
to  complete  the  precipitation  of  albu- 
min as  to  avoid  mistakes  caused  by 
the  presence  of  a  precipitate  of  phos- 
phates or  carbonates, — which  will 
immediately   dissolve  when  nitric  acid 


is  added.  This  test  is  very  delicate 
and  will  reveal  0.01  to  0.005  per 
cent,  of  albumin.  Instead  of  nitric 
acid,  acetic  acid  can  be  employed, 
but,  while  the  nitric  acid  is  to  be 
added  after  boiling  and  in  a  quan- 
tity of  5  to  10  drops,  acetic  acid  is 
added  before  the  boiling,  and  only  a 
sufficient  quantity  (1  to  2  drops) 
should  be  employed  as  to  make  the 
urine  but  slightly  acid.  This  is  espe- 
cially necessary  when  the  urine  is 
alkaline,  because  the  alkaline  albumi- 
nates with  a  surplus  of  acetic  acid 
give  a  compound  which  is  not  coagu- 
lated by  boiling. 

Tretrop  heats  the  urine  nearly  to  a 
boiling  point  and  adds  a  few  drops  of 
a  40  per  cent,  solution  of  formalin. 
The  albumin  coagulates  like  white  of 
egg.  After  pouring  off  the  fluid,  the 
proportion  of  albumin  can  be  deter- 
mined by  weighing  the  coagulum  left. 

Bj^chowski  describes  the  following 
simple  method  to  detect  the  presence 
of  albumin,  even  if  only  a  few  drops 
of  urine  can  be  obtained:  One  or  2 
drops  of  urine  are  put  in  a  test-tube 
of  hot  water.  After  shaking,  a 
whitish  cloud  is  formed,  if  albumin  is 
present.  The  test  is  very  distinctive 
and  is  still  more  apparent  when  the 
test-tube  is  held  against  a  black  back- 
ground. Of  course,  phosphates  give 
the  same  reaction,  but  the  cloud  dis- 
appears on  the  addition  of  a  drop  of 
acetic  acid. 

Test  for  albumin  in  the  urine  in 
which  the  extra  work  of  having  a  con- 
trol or  the  filtering  of  the  urine  or  the 
modification  of  its  reaction  has  been 
eliminated. 

Material  needed  for  the  test :  Satu- 
rated salt  solution,  acetic  acid,  test- 
tube,  pipette. 

On  heating  urine  three  substances 
may  be  thrown  down :  albumin,  nucleo- 


ALBUMINURIA    (LEVISON    AND    ERLANDSEN). 


501 


protcid,  and  phosphates.  About  5  to 
10  c.c.  of  saturated  salt  solution,  slightly- 
acidulated  with  acetic  acid,  is  heated  to 
boiling  in  a  test-tube.  The  urine  to 
be  tested  is  carefully  allowed  to  run 
on  top  of  the  hot  salt  solution  by 
means  of  the  pipette.  In  order  to 
make  a  good  picture,  the  quantity  of 
urine  used  ought  to  equal  that  of  the 
salt  solution. 

By  means  of  the  heat  in  the  sat- 
urated acidulated  '  salt  solution  the 
above-mentioned  substances  are  likely 
to  be  precipitated,  but,  owing  to  the 
contact,  the  saturated  salt  will  not 
let  the  nucleoproteids  appear,  while 
the  phosphates  are  also  held  in  sus- 
pension by  the  acid ;  hence  nothing  can 
appear  at  the  point  of  contact  of  the 
hot  saturated  salt  with  the  urine  except 
albumin. 

Depending  on  the  quantity  of  albumin 
present  the  reaction  will  be  marked  or 
only  a  film  will  appear  overlying  the 
clear,  crystal-like  salt  solution.  It  is  in 
urine  with  a  trace  of  albumin  in 
which  this  test  shows  extreme  delicacy. 
The  clear,  crystal-like  salt  solution  and 
the  control-column  of  urine  above  with 
the  surface  of  contact  contrast  quite 
decisively  in  distinguishing  a  delicate 
cloud. 

Different  pictures  are  produced  in  the 
great  variety  of  urines  by  means  of 
this  technique : — 

1.  In  clear  urine  which  contains  no 
albumin  the  delicate  point  of  contact 
where  the  urine  rides  the  hot  salt  solu- 
tion is  better  brought  out  by  setting 
the  solution  in  motion  by  gently  shak- 
ing the  tube  to  and  fro. 

2.  In  clear  urine  sometimes  a  cloud 
appears  some  distance  above  the  point 
of  contact.  This  is  due  to  the  heat, 
which,  traveling  farther  and  faster  than 
the  acid  of  the  salt  solution,  throws 
down  a  phosphate  cloud. 

3.  Cloudy  urine  due  to  phosphates  or 
urates  is  cleared  at  the  point  of  contact 
because  the  acid  and  the  heat  dissolve 
these,  respectively. 

4.  In  cloudy  urine  due  to  bacteria  no 
change  is  seen  in  the  urine  at  the  point 
of  contact,  and  here,  at  times,  only  a 
close   scrutiny   of   the   urine   above   the 


crystal-like  salt  solution  below  in  com- 
parison with  the  zone  of  contact  will 
give  us  the  correct  reading. 

5.  In  urine  containing  albumin 
clouded  by  urates  or  phosphates,  the 
albumin  cloud  at  the  contact  dififers  in 
density  from  the  remainder  of  the 
urine.  Often  the  film  of  coagulated 
albumin  is  so  delicate  that  the  clearing 
of  urates  or  phosphates  is  again  seen 
above  that  of  the  contact  zone. 

6.  In  albuminous  urine  clouded  by 
bacteria  the  coagulated  albumin  at  the 
point  of  contact  accentuates  its  pres- 
ence by  its  difference  in  density. 

It  is  in  cloudy  urine  that  the  control 
of  a  clear,  crystal-like  liquid  below  the 
urine  above  emphasizes  the  beauty  of 
the  reaction  in  the  zone  of  contact. 

This  test  is  a  modification  of  the 
saturated  salt,  or  brine,  test,  yet  it  adds 
to  this  old  method  the  new  qualities  of 
diminished  labor,  simplicity,  and  ac- 
curacy. H.  L.  Ulrich  (Jour.  Minn. 
State  Med.  Assoc,  Feb.  15,  1909). 

Method  of  employing  the  acetic 
acid  test  for  the  detection  of  albumin 
which  has  long  been  used  in  France: 
20  c.c.  of  urine,  about  three-fourths 
of  a  test-tube  1.5  cm.  in  diameter,  are 
treated  with  5  drops  of  20  per  cent, 
acetic  acid,  mixed,  and  one-half 
poured  into  a  second  test-tube.  The 
contents  of  one  tube  are  boiled,  the 
other  serving  as  a  control.  Albumin 
produces  a  cloud  or  precipitate  in  the 
boiled  tube.  Before  testing,  the 
urine  must,  of  course,  be  perfectly 
clear;  if  necessary,  it  is  shaken  with 
Kieselguhr  and  filtered.  If  the  acetic 
acid  causes  a  cloud  in  the  cold 
(nucleoalbumin),  it  is  cleared  by 
filtration  before  boiling.  An  alkaline 
urine  should  be  acidulated  slightly  to 
prevent  the  precipitation  of  the  phos- 
phates, or,  if  a  precipitate  of  phos- 
phates appears  when  the  urine  has 
been  treated  with  acetic  acid  and 
boiled,  a  few  more  drops  of  the  dilute 
(20  per  cent.)  acid  may  be  added  to 
dissolve  it.  This  will  not  redissolve 
even  a  slight  albuminous  cloud,  pro- 
vided the  urine  is  not  boiled  again. 
Glaesgen  (Miinch.  med.  Woch.,  Bd. 
Iviii,  S.  1123,  1911). 


502 


ALBUMINURIA    (LEVISON    AND    ERLANDSEN). 


Heller's  Test. — Three  to  4  c.c.  of 
nitric  acid  are  poured  in  a  test-tube 
and  a  few  c.c.  of  urine  are  cautiously 
filtered  down  along  the  sides  of  the 
tube  without  shaking  the  latter.  The 
nitric  acid  rests  on  the  bottom  of  the 
test-tube,  and  where  the  fluids  are  in 
contact  a  distinctly  limited  disk  of 
grayish-white  precipitate  will  appear. 
When  only  traces  of  albumin  are  pres- 
ent the  precipitate  will  only  take  place 
after  some  minutes.  The  more  or  less 
distinct  violet  coloring  which  also  ap- 
pears at  the  point  of  contact  of  the  two 
fluids  is  due  to  oxidation  of  indican  or 
other  chromogens.  This  test  is  very 
delicate  and  reliable;  0.003  per  cent, 
of  albumin  is  revealed  by  it. 

Fallacies. — By  the  addition  of  nitric 
acid  the  urates  or  urea  are  also  pre- 
cipitated ;  these  wnll  not  form  a 
limited  disk,  but  render  the  urine 
turbid.  Resinous  acids  (copaiba, 
etc.)  are  precipitated  by  nitric  acid, 
but  are  dissolved  by  the  addition  of 
concentrated  alcohol.  This  error  can 
be  avoided  by  diluting  the  urine  or 
by  moderately  warming  the  nitric 
acid  before  the  test.  Very  often  also 
a  fine  disk  or  ring  will  appear  above 
the  point  of  contact.  This  precipita- 
.tion  is  due  (Morner)  to  the  presence 
of  nucleoalbumins  (mucin,  chondrolin, 
sulphuric  acid,  etc.)  and  is  more  dis- 
tinct after  dilating  the  urine. 

Test  by  Acetic  Acid  and  Potassic 
Ferrocyanide. — The  urine  is  rendered 
acid  by  acetic  acid,  and  some  drops  of 
a  solution  of  potassic  ferrocyanide  are 
added.  This  reagent,  the  serum-albu- 
min, the  globulin,  and  the  albumoses  are 
precipitated,  while  none  of  the  normal 
constituents  of  the  urine  are  (Huppert). 

Heynsius's  Test. — A  still  more  deli- 
cate test  than  Heller's  is  that  of  Heyn- 
sius,  by  acetic  acid  and  sulphate  of  soda. 


The  urine  is  rendered  acid  by  acetic 
acid,  and  an  equal  vplume  of  a  saturated 
solution  of  sulphate  of  soda  (or  of 
common  salt)  is  added.  The  mixture  is 
boiled,  and  all  kinds  of  albumin  will 
then  be  precipitated  in  white  flakes. 

The  Magnesium-nitric  Test  (Rob- 
erts's).— One  c.c.  of  nitric  acid  is 
mixed  with  5  c.c.  of  a  saturated  solu- 
tion of  sulphate  of  magnesium,  and  a 
small  quantity  of  this  mixture  is 
•  added  to  the  urine.  The  albumin  will 
be  precipitated  as  a  distinct  ring. 

Metaphosphoric  Acid  (Hinden- 
lang's)  also  precipitates  albumin  in 
the  same  manner  as  nitric  acid ;  but  this 
test  is  not  as  delicate  as  that  of  Heller. 
The  solution  of  metaphosphoric  acid 
must  be  freshly  prepared  for  use,  as  the 
solution  easily  changes  to  orthophos- 
phoric  acid  upon  standing,  which  does 
not  precipitate  albumin. 

Picric  Acid  Test  (Johnson's). — A 
few  drops  of  a  saturated  solution  of 
picric  acid  will  cause  a  white  precipitate 
when  albumin  is  present;  this  test  is 
only  indicative  of  the  presence  of  albu- 
min, however,  when  the  precipitate 
appears  immediately.  The  urine  must 
be  acid.  After  some  time  the  uric  acid 
and  the  creatinine  will  also  be  pre- 
cipitated (Jaffe). 

Fallacies. — By  addition  of  picric  acid 
and  peptones,  the  resinous  acids, — such 
as  those  of  copaiba, — and  alkaloids — 
such  as  morphine — are  precipitated. 

Perchloride-of-niercury  or  Spiegler 
Test. — A  solution  of  8  grams  of  mer- 
cury, 4  grams  of  tartaric  acid,  20  grams 
of  glycerin  in  200  grams  of  water  pro- 
duces a  precipitate  of  albumin.  The 
test  is  carried  out  in  the  same  manner 
as  Heller's  test.  It  is  very  delicate  (it 
reveals  0.0002  per  cent,  of  albumin), 
but  is  not  reliable  when  the  urine  is  poor 
in  chlorides  (Jolles). 


ALBUMINURIA    (LEVISON    AND    ERLANDSEN). 


503 


Millon's  Test. —  A  solution  of  nitrate 
of  mercury  is  added  to  the  urine  and 
the  mixture  heated  to  boihng.  Nitrate 
of  potash  is  then  added;  the  albumin 
presents  as  a  precipitate  of  red  flakes. 
This  test  is  disturbed  by  the  sodium 
chloride  of  the  urine  and  will  be  much 
better  if  tried  upon  the  precipitate  after 
boiling  the  urine. 

Tanret's  Test. — The  reagent  of 
Tanret  is  composed  of  perchloride  of 
mercury,  135  grams ;  iodide  of  potash, 
Z.Z2  grams ;  glacial  acetic  acid,  20 
c.c. ;  distilled  water,  sufficient  to  make 
100  c.c. 

Some  drops  of  this  mixture  are  added 
to  the  urine,  when  it  will  coagulate  the 
albumin.  It  will  also,  however,  pre- 
cipitate the  urates. 

Tognetti  described  a  "tannohydro- 
chloric"  test  which  reveals  albumin, 
even  in  a  proportion  of  1  to  2,000,000. 
An  equal  amount  of  1.5  per  cent,  alco- 
holic solution  of  tannin  is  added  to  the 
urine.  After  heating,  an  equal  amount 
of  33  per  cent,  hydrochloric  acid  is 
added.  A  yellowish-white  precipitate 
is  gradually  thrown  down. 

The  advantages  of  tannic  acid  as  a 
reagent  for  albumin  have  long  been 
known,  but  it  could  not  be  used  in  urine, 
as  other  ingredients  of  the  urine  also 
give  a  positive  response.  This  difficulty- 
has  been  removed  by  the  adoption  of 
the  following  technique,  which,  the  writer 
says,  renders  the  test  reliable,  instruc- 
tive, and  extremely  sensitive.  An  equal 
amount  of  an  alcoholic  solution  of  tan- 
nin (1.5  Gm.  of  tannin  in  100  c.c.  of 
90  per  cent,  alcohol)  is  added  to  the 
urine.  The  whole  is  then  heated  and 
an  equal  quantity  of  a  33  per  cent, 
aqueous  solution  of  hydrochloric  acid 
is  added — equal  to  the  quantity  of  urine. 
In  the  presence  of  albumin,  the  fluid 
becomes  opaque  and  the  albumin  is 
gradually  thrown  down  in  a  yellowish- 
white  precipitate.  In  case  of  icterus, 
the  bile  pigments  must  first  be  removed 


by  the  Grocco  technique,  that  is,  by  add- 
ing glacial  acetic  acid  in  the  proportion 
of  one-thirtieth  or  one-fiftieth  of  the 
amount  of  urine.  With  the  exception 
of  this  precaution,  which  is  necessary 
with  other  tests  for  albumin,  the  tanno- 
hydrochloric  test,  he  declares,  can  be 
regarded  as  free  from  causes  of  error. 
The  combination  of  tannic  acid,  hydro- 
chloric acid,  alcohol,  and  heat  elimi- 
nates the  usual  drawbacks  of  tests  for 
albumin.  A.  Tognetti  (Gaz.  degli 
Ospedali,  vol.  xxvii.  No.  60,   1906). 

Colquhoun  recommends  a  solution  of 
carbolic  acid  in  absolute  alcohol;  this 
gives  a  white,  milky  precipitation  of 
albumin.  The  test  is  said  to  show  0.002 
per  cent,  albumin. 

A  solution  of  carbolic  acid  in  abso- 
lute alcohol  is  a  very  delicaie  test  for 
albumin  in  the  urine,  comparing  very 
■favorably  with  nitric  acid.  The  urine 
should  first  be  diluted  until  the  specific 
gravity  is  about  1.010;  a  few  c.c.  of 
carbolic  acid  are  then  poured  on  top  of 
this,  and  a  white  ring  is  immediately 
formed,  from  which  milky  drops  fall 
to  the  bottom  of  the  tube,  and  adher- 
ing to  this  are  the  flakes  of  albumin. 
The  test  is  sufficiently  delicate  to  show 
0.000012  gram  in  1  c.c.  of  urine.  W. 
Colquhoun  (Lancet,  May  6,  1900). 

Many  other  reagents  have  been 
recommended,  which  cannot  be  men- 
tioned in  detail.  The  boiling  test.  Hel- 
ler's test,  the  potassic  ferrocyanide  test, 
and  the  picric  acid  test  are  the  most 
practicable  and  quite  sufficient  in  gen- 
eral work. 

Xanthoprotein  Test. — Albuminous 
urine  heated  with  a  surplus  of  con- 
centrated nitric  acid  will  take  a  yellow 
color,  and  some  of  the  albumin  coagu- 
lates in  yellow  flakes,  which  are  soluble 
in  alkalies  with  an  orange-red  color. 

Very  minute  quantities  of  albumin 
may  be  detected  in  the  urine  b}^  means 
of  the  deviation-of-complement  test. 
For  antigen  the  writer  has  used  the 
serum  of  rabbits  which  had  been  im- 
munized   against    human    blood-serum. 


504 


ALBUMINURIA    (LEV150N    AND    ERLANDSEN). 


When  albuminous  urines  were  diluted 
to  such  a  point  that  they  no  longer 
gave  a  reaction  with  heat  and  acetic 
acid  or  with  nitric  acid,  they  still 
yielded  positive  results  by  the  comple- 
ment-deviation test,  while  in  many 
instances  albumin  could  be  detected  by 
this  method  in  diluted  urine  when  it 
could  not  be  demonstrated  by  the  ordi- 
nary chemical  tests.  The  deviating 
power  of  the  urine  is  not  affected  either 
by  filtration  through  a  Berkefeld  filter 
or  by  dialysis.  The  antibody  of  the 
urine  was,  moreover,  found  to  reside 
entirely  in  the  serum  albumin  and 
serum  globulin,  and  after  the  removal 
of  the  substances  from  the  urine  the 
remaining  fluid  no  longer  had  the 
property  of  an  antibody.  C.  H.  Wilson 
(Jour.  Path,  and  Bact,  vol.  xiii,  p. 
484,  1909). 

Following  are  two  new  qualitative 
tests  for  albumin  in  urine,  which  are 
apparently  specific  as  well  as  simple. 
The  first  test  is  with  tincture  of  iodine 
and  sodium  bisulphate :  A  few  c.c. 
(5  to  6)  of  the  urine — which  must,  of 
course,  be  clear — are  placed  in  a  test- 
tube  and  acidified  with  a  few  drops  of 
dilute  acetic  acid.  About  %  volume  of 
tincture  of  iodine  (10  per  cent.)  is  now 
added,  and  the  whole  is  well  shaken. 
A  dirty,  dark-brown  precipitate  results. 
A  saturated  solution  (watery)  of 
sodium  bisulphate  is  next  added  drop 
by  drop,  shaking  constantly,  until  the 
brownish  fluid  is  decolorized.  If  the 
urine  contains  albumin,  one  sees  a 
permanent  whitish  cloud  or  flocculent 
precipitate.  If  no  albumin  is  present, 
the  fluid  remains  clear  after  the  addi- 
tion of  the  sodium  bisulphate,  and 
shows  only  the  original  urinary  color. 
With  minimal  quantities  of  albumin, 
the  reaction  becomes  more  evident  on 
standing  a  few  minutes.  The  second 
is  with  decolorized  tincture  of  iodine : 
One  decolorizes  tincture  of  iodine  with 
saturated  watery  solution  of  sodium 
bisulphate  and  filters.  The  filtrate  is 
a  clear,  rather  yellowish  fluid,  which 
keeps  well.  On  standing  for  some  time, 
small,  yellow  crystals  may  be  precipi- 
tated, without  injury  to  the  reagent. 
The  urine,  as  in  the  first  test,  is  acidi- 


fied with  dilute  acetic  acid.  About  Ys 
volume  of  the  reagent  is  added  and  the 
whole  well  shaken.  If  albumin  is 
present,  a  cloud  or  a  flocculent  white 
precipitate  forms.  With  traces  of  al- 
bumin the  reaction  may  be  delayed  a 
few  minutes.  Normal  urine  never 
shows  a  cloud  with  these  tests.  Oguro 
(Zeit.  f.  exper.  Path.  u.  Therap.,  Bd. 
vii,  S.  349,  1909;  Amer.  Jour.  Med. 
Sci.,  Jan.,  1910). 

Aufrecht's  method  is  to  be  preferred. 
It  consists  of  centrifugating  the  urine, 
mixing  with  4  c.c.  of  urine  3  c.c.  of  an 
aqueous  solution  of  l.S  per  cent,  picric 
acid  and  3  per  cent,  citric  acid.  The 
results  are  reliable,  while  the  method  is 
simple,  rapid,  and  practical,  and  can  be 
applied  to  any  organic  fluids,  and  also 
for  determination  of  propeptones  in 
urine  after  filtering  out  the  albumin, 
cooling  and  centrifugating  anew.  Kop- 
pang  (Norsk  Mag.  f.  Laegevidenska- 
ben,   Sept.,   1910). 

Transportable  Reagents  for  Albu- 
min.— Hoffmann  and  Aazette  employ 
strips  of  test-paper  previously  placed  in 
a  solution  of  the  double  iodide  of  potas- 
sium and  mercury  until  saturated,  then 
removed  and  dried.  Geissler's  albumin- 
test  paper  is  previously  placed  in  a  solu- 
tion of  citric  acid.  The  urine  which  is 
to  be  tested  should  be  clear  and  ren- 
dered acid  by  means  of  a  few  drops  of 
acetic  acid.  If  there  be  albumin  pres- 
ent, upon  immersion  of  a  slip  of  paper 
in  the  urine  a  distinct  precipitate  will 
appear. 

Pavy  recommends  test-pellets  con- 
taining ferrocyanide  of  soda  and  picric 
acid;  when  albuminous  urine  is  well 
shaken  with  a  parcel  of  the  pellet,  albu- 
min will  be  precipitated.  Stiitz  and 
Fiirbringer  employ  oapsuloids  of  gela- 
tin filled  with  perchloride  of  mer- 
cury, sodium  chloride,  and  citric  acid. 
The  relative  delicacy  of  the  tests  most 
frequently  employed  is  graphically  rep- 
resented   by    Unger-Vetlesen^    in    the 


ALBUMINURIA    (LEVISON    AND    ERLANDSEN). 


505 


diagram  shown  below.  The  longest 
columns  indicate  the  most  delicate  tests. 
Quantitative  Tests.  —  The  only 
method  which  gives  fully  reliable  re- 
sults is  the  gravimetric  method.  One 
hundred  c.c.  of  urine  are  boiled  upon 
a  water-bath  half  an  hour ;  if  precipi- 
tation does  not  take  place  a  few  drops 
of  a  weak  solution  of  acetic  acid  are 
added;  the  liquid  is  now  brought  on 
a  ■  weighed   filter  and   the   precipitate 


Ferrocyanide     of    potassium     and 
acetic  acid 

Solution  of  picric  acid 

Test-paper 

Solution  of  sulphate  of  soda  and 
acetic  acid 

Heller's  test   

Picric  acid  in  cr\'Stals 

Magnesium-nitric  test   (Roberts)  . 

Trichloracetic  acid 

Metaphosphoric  acid   

Boilinsr  and  nitric  acid 


repeatedly  washed  with  hot  water. 
The  filtrate  must  once  more  be  acidu- 
lated with  acetic  acid  and  boiled 
ag?.in,  in  order  to  ascertain  whether 
the  precipitation  has  been  quantita- 
tive. AMien  the  water  has  been 
removed  from  the  filter  by  strong 
alcohol,  and  the"  alcohol  with  pure 
ether,  the  filter  is  dried  at  a  tempera- 
ture of  110°  to  120°  C,  and  the  per- 
centage of  albumin  determined  by 
Aveighing. 

For    clinical    use    several    approxi- 
mate methods  have  been  invented. 


Esbach  employs  an  albuminimeter, 
i.e.,  a  graduated  glass  tube ;  this 
tube  is  filled  to  one  mark  {U)  with 
the  urine  and  then  to  the  mark  R 
with  the  test-solution  consisting  of 
picric  acid,  10  grams;  citric  acid,  20 
grams;  water,  1  liter.  The  tube  is 
then  closed  with  a  rubber  stopper  and 
the  contents  cautiously  mixed  (not 
shaken).  The  mixture  is  allowed  to 
stand     undisturbed     for    twenty-four 


12 

24 

35 

48 

60 

■J72 

84 

96 

\6% 

W/MMM> 

i-'v/w^y^/^ii^/ 

• 

f^^ 

^i 

l» 

hours  and  the  quantity  of  precipitated 
albumin  then  read  off.  The  reading 
indicates  in  grams  the  amount  of 
albumin  per  liter.  The  urine  must 
be  acid,  the  specific  weight  should 
not  be  more  than  1006  to  1008,  and 
the  temperature  of  the  room  approxi- 
mately constant  (15°  C).  Resinous 
acids  must  be  extracted  with  ether. 
The  yellow  crystals  often  found  on 
the  side  of  the  glass  are  crystals  of 
uric  acid. 

Christensen     recommends     another 
method :   the  albumin  contained  in  5 


506 


ALBUMINURIA    (LEVISON    AND    ERLANDSEN). 


c.c.  of  urine  is  precipitated  by  10 
c.c.  of  a  watery  solution  of  tannic 
acid  (1  per  cent.).  The  albumin 
having  been  precipitated,  1  c.c.  of 
an  ordinary  gum-arabic  mucilage  is 
added,  the  volume  brought  up  to  50 
c.c.  with  water,  and  the  whole  con- 
verted to  an  emulsion  by  agitation. 
Upon  a  piece  of  white  paper,  ruled 
with  black  lines  0.5  mm.  wide  and 
at  equal  intervals,  is  placed  a  cylin- 
drical glass  measuring  4  cm.  in 
diameter.  This  is  half-filled  with 
water,  and  as  much  of  the  emulsion 
run  in  as  possible  without  obscuring 
the  black  and  white  lines  beneath  the 
vessel.  From  the  number  of  cubic 
centimeters  required,  reference  to  a 
table  of  calculations  arranged  by 
Christensen  furnishes  the  proportion 
of  albumin  present  in  the  emulsion. 
When  the  urine  is  alkaline  it  should 
be  faintly  acidified  with  acetic  acid 
before  the  precipitation  of  albumin. 
This  test  can  be  made  as  well  by 
daylight  as  by  the  light  of  a  good 
lamp,  and  requires  only  ten  or  fifteen 
minutes;  but  is  not  applicable  to 
urine  containing  a  small  amount  of 
albumin,  the  variations  amounting  to 
two-thousandths. 

The  polariscope  is  sometimes  em- 
ployed to  estimate  the  quantity  of 
albumin,  but  this  test  is  not  reliable. 
It  is  true  that  albumin  is  levorota- 
tory,  but  this  is  also  the  case  with 
normal  urine,  and  sometimes  the 
color  of  the  urine  is  too  dark  to  allow 
the  use  of  the  polariscope. 

Goodman  and  Stern  have  pointed 
out  (1908)  a  quantitative  method 
which  gives  results  in  a  few  minutes. 
It  is  based  on  the  precipitation  of 
albumin  by  phosphotungstic  acid  in 
the  presence  of  a  mineral  acid.  One 
gram    of    crystallized    egg-albumin    is 


dissolved  in  100  c.c.  of  distilled  water 
(solution  A)  ;  1  c.c.  of  this  solution 
is  diluted  with  9  c.c.  of  distilled  water 
(solution  B),  Drop  in  a  test-tube  5 
c.c.  of  the  following  solution : — 

5  Phosphotungstic  acid   1.5  Gm. 

Hydrochl.  acid   (cone.)    5  c.c. 

Alcohol   (95  per  cent.) .  .q.  s.  ad  100  c.c. 

Now  it  takes  0.1  cm.  (added  with 
a  pipette  graduated  in  0.1  c.c.)  of 
solution  B  to  cause  a  cloudy  pre- 
cipitate, i.e.,  0.0001  Gm.  of  albumin. 
The  diluted  urine  is  tested  in  the 
same  manner. 

Miscellaneous. — By  the  tests  above 
mentioned,  as  well  qualitative  as 
quantitative,  the  different  coagulable 
proteids  contained  in  the  urine  are 
precipitated ;  it  is  rarely  of  any  use  to 
differentiate  them  one  from  another. 

Pure  globulinuria  without  the 
simultaneous  presence  of  serum- 
albumin  does  not  occur.  In  order  to 
precipitate  the  globulin  alone  the 
urine  is  rendered  alkaline  with  solu- 
tion of  ammonia,  after  some  time 
filtered,  and  the  filtrate  mixed  with 
an  equal  volume  of  a  saturated  solu- 
tion of  sulphate  of  ammonia.  If  glob- 
ulin be  present  a  flaky  precipitate  will 
appear.  - 

[The  same  result  can  be  obtained  by  using 
a  solution  of  sulphate  of  magnesia,  which 
does  not  precipitate  the  other  proteids  of 
urine,  or  by  diluting  the  urine  until  it  reaches 
a  specific  gravity  of  1002  and  leading  a  slow 
current  of  carbonic  acid  through  it  for  two 
or  four  hours.  After  twenty-four  to  twenty- 
eight  hours  the  globulin  will  be  precipitated. 
Levison.] 

The  albumoses  often  found  in  the 
urine    seem   to  be   a   mixture   of    deu- 
teroalbumoses  and  protalbumoses. 
F.  Levison 

AND 

A.    Erlandsen, 

Copenhagen. 


ALCOHOL    (SAJOUS). 


507 


ALCOHOL.— Alcohol  is  one  of 

a  group  of  hydrocarbon  compounds 
which  have  as  their  base  a  radical  desig- 
nated as  ethyl,  chemically  represented 
by  the  formula  C2H5.  Alcohol  is  a  hy- 
drate or  hydroxide  of  ethyl — C0H5OH. 
To  distinguish  it  from  other  more  toxic 
members  of  the  series  of  alcohols,  par- 
ticularly fusel  oil  (chiefly  amyl  alcohol) 
and  wood  spirit  (methyl  alcohol),  the 
spirit  used  in  medicine  is  called  ethyl 
alcohol.  It  is  obtained  by  distillation 
and  subsequent  purification  from  a  fer- 
mented mash  of  potatoes  or  grain,  from 
fermented  sugar,  or  from  wine,  and  is 
known  in  the  British  Pharmacopeia  as 
rectified  spirit. 

Absolute  alcohol,  i.e.,  alcohol  at  least 
99  per  cent,  pure,  occurs  as  a  volatile, 
inflammable,  colorless  liquid,  with  a 
characteristic  pungent  odor  and  burn- 
ing taste.  Its  boiling  point  is  172°  F. 
(77.7°  C).  It  has  a  marked  affinity  for 
water,  which  it  abstracts  from  whatever 
substances  it  may  be  in  contact  with, 
including  the  air  and  the  human  tissues. 
It  is  miscible  in  all  proportions  with 
water,  glycerin,  ether  and  chloroform. 
When  absolute  alcohol  is  mixed  with 
water  the  resulting  volume  of  fluid  is 
slightly  less  than  the  sum  of  the  two 
components  before  their  admixture. 

Alcohol  is  a  solvent  for  resins, 
volatile  oils,  fats,  and  alkaloids,  and 
is  very  extensively  employed  as  such 
in  preparations  containing  remedies 
of  these  classes,  most  of  which  are 
insoluble  in  water.  It  forms  the  mens- 
truum in  the  official  tinctures,  spirits, 
elixirs,  and  all  but  two  of  the  fluid- 
extracts. 

PREPARATIONS  AND  DOSE. 

Alcohol  contains  94.9  per  cent,  by 
volume  (92.3  per  cent,  by  weight  of 
pure  ethyl  alcohol  to  5.1  per  cent,  of 
water).  Specific  gravity,  0.816.    Rarely 


used  internally  in  doses  of  1  to  4  drams, 
diluted  with  water. 

Alcohol  Absolutum  (Absolute  Al- 
cohol) contains  not  more  than  1  per 
cent,  by  weight  of  water.  Specific 
gravity,  0.797. 

Alcohol  Dilutum  (Diluted  Alco- 
hol).— A  mixture  of  alcohol  and  dis- 
tilled water,  containing  48.9  per  cent,  by 
volume  (about  41.5  per  cent,  by  weight) 
of  pure  ethyl  alcohol  to  51.1  per  cent,  of 
water.     Specific  gravity  about  0.937. 

Spiritus  Frumenti  (Whisky) . — 44 
to  55  per  cent,  by  volume  of  absolute 
alcohol. 

Spiritus  Vini  Gallic!  (Brandy). — 
46  to  55  per  cent,  by  volume  of  absolute 
alcohol. 

Vinum  Album  (White  Wine). — 8.5 
to  15  per  cent,  by  volume  of  absolute 
alcohol. 

Vinum  Rubrum  (Red  Wine). — 8.5 
to  15  per  cent,  by  volume  of  absolute 
alcohol. 

Whisky  is  produced  by  the  distillation 
of  fermented  grain  (rye,  corn,  or  bar- 
ley), and  brandy  by  the  distillation  of 
fermented  grapes.  Inasmuch  as  the 
toxic  amylic  alcohol  is  likely  to  be  pres- 
ent in  freshly  distilled  spirits,  the  Phar- 
macopeia specifies  that  these  products 
shall  have  been  kept  in  storage  for  a 
certain  period  before  use  (whisky,  two 
years;  brandy,  four  years),  the  amylic 
alcohol  becoming  oxidized  into  harmless 
ethers.  White  wine  results  from  the 
fermentation  of  the  juice  of  fresh 
grapes,  from  which  the  skins,  seeds  and 
stems  have  been  removed,  while  red 
wine  is  produced  from  purple-colored 
grapes  with  the  skins  included.  The 
latter  contains  more  tannin,  but  less  tar- 
taric acid  than  white  wine. 

Dose. — The  ordinary  dosage  of 
whisky  or  brandy  in  adults  unaccus- 
tomed to  their  use  may  be  said  to  range 


508 


ALCOHOL    (SAJOUS). 


from  1  dram  (4  c.c.)  to  2  ounces  (60 
c.c).  In  regulating  the  dose  the  capac- 
ity of  the  individual  to  oxidize  the  alco- 
hol is  to  be  taken  into  account, the  object 
being,  if  alcohol  is  to  be  given  repeat- 
edly, to  limit  the  amount  to  that  which 
can  be  destroyed  in  or  eliminated  from 
the  organism  in  the  interval  between 
successive  doses.  According  to  Bartho- 
low,  the  quantity  which  a  healthy  adult 
is  able  to  oxidize  in  twenty-four  hours 
is  from  1  to  1>4  ounces  of  absolute  al- 
cohol. Where  this  is  exceeded,  an  accu- 
mulation of  the  drug  in  the  system  is 
likely  to  occur,  and  the  following  symp- 
toms may  be  expected  to  appear.  Flush- 
ing of  the  face,  dryness  of  the  skin  and 
mucous  mebranes,  bounding  pulse,  and 
the  odor  of  alcohol  on  the  breath.  Such 
signs  indicate,  in  any  given  case,  that 
the  useful  amount  of  alcohol,  whether 
employed  for  general  or  merely  for  di- 
gestive stimulation,  is  being  exceeded. 
In  persons  habitually  taking  alcoholic 
beverages  the  ability  to  oxidize  alcohol 
is  augmented,  finding  its  expression  in 
increased  tolerance ;  hence  in  these  indi- 
viduals, if  alcohol  is  given  for  the  pur- 
pose of  obtaining  therapeutic  effects, 
the  dose  will  have  to  be  increased,  and 
even,  in  many  cases,  doubled  or  tripled. 
In  febrile  states  large  amounts  have 
often  been  administered  without  caus- 
ing signs  of  intoxication,  the  oxidizing 
power  evidently  being  heightened  dur- 
ing the  febrile  process ;  notwithstanding 
this  fact,  it  is  now  generally  considered 
that  small  doses  of  alcohol — if,  indeed, 
it  be  used  at  all  in  these  cases  other  than 
during  periods  of  dangerous  circulatory 
depression — will  give  as  good  results  as 
large  amounts. 

In  children,  as  well  as  in  the  aged, 
alcohol  is  well  borne.  To  the  former  it 
can  be  administered  in  doses  proportion- 
ally larger  than  are  suitable  for  adults, 


while  in  the  latter  the  dose  need  not  be 
reduced  from  that  given  to  the  middle- 
aged. 
MODES  OF  ADMINISTRATION. 

— Alcohol,  as  used  in  therapeutics,  is 
usually  exhibited  in  dilute  form  in  one 
of  the  various  spirituous  beverages,  the 
majority  of  which  are  non-official.  They 
may  conveniently  be  grouped  according 
to  the  percentage  of  alcohol  contained. 

The  so-called  "spirits"  include  whisky, 
brandy,  gin,  rum,  and  arrack,  and  all 
contain  about  50  per  cent,  of  alcohol.  A 
liquor  having  this  percentage  is  said  to 
be  "proof  spirit,"  implying  that  it  con- 
tains just  sufficient  alcohol  to  be  inflam- 
mable. Gin  ("spiritus  Genevse")  is 
made  by  adding  oil  of  juniper  berries  to 
rectified  alcohol  or  whisky.  The  offi- 
cial spiritus  juniperi  compositus,  with  4 
per  cent,  of  juniper  oil  as  well  as  other 
flavoring  substances,  is  a  preparation 
similar  to  gin,  but  is  stronger  in  alcohol, 
containing  70  per  cent. ;  the  average 
dose  is  2  drams.  Rum  ("spiritus  Jamai- 
censis")  is  obtained  by  distilling  fer- 
mented molasses  or  sugar.  Like  gin,  it 
is  not  official.  Arrack  results  from  the 
distillation  of  fermented  rice.  Spirits 
contain  a  large  number  of  other  volatile 
bodies  besides  the  main  component, 
ethyl  alcohol.  These  include  higher 
members  of  the  same  group  of  alco- 
hols as  ethyl  alcohol,  as  well  as  alco- 
hols of  other  series  and  a  group  of 
bodies  the  composition  of  which  re- 
mains obscure,  known  as  the  oenanthic 
ethers,  and  which,  though  present  in 
small  amounts,  give  to  the  various 
liquors  their  characteristic  flavors.  Spir- 
its differ  radically  from  wines  in  that 
they  are  free  of  non-volatile  compounds, 
which  are  left  behind  in  the  process  of 
distillation. 

The  heavy  wines  contain  about  20  per 
cent,  of  alcohol,  being  made  from  grapes 


ALCOHOL    (SAJOUS). 


509 


having  a  large  proportion  of  sugar. 
They  inchule  port,  sherry,  Madeira, 
Marsala,  Malaga,  and  others.  Port 
(formerly  official  as  "vinum  portense") 
is  a  sweet,  red  wine,  containing  15  to  22 
per  cent,  of  alcohol ;  its  sweetness  is  due 
to  arrest  of  the  process  of  fermentation 
while  still  incomplete.  Sherry  ("vinum 
Xerici")  is  a  white  wine,  containing  15 
to  18  per  cent,  of  alcohol.  Port  and 
sherry  of  American  production  are  usu- 
ally lighter,  the  percentages  ranging 
from  10  to  18.  Madeira  is  a  dark-col- 
ored white  wine  with  18  to  22  per  cent, 
of  alcohol.  Marsala  is  a  wine  similar 
to  Madeira,  but  of  Sicilian  production. 
Malaga  is  a  sweet  wine,  having  17  per 
cent,  of  alcohol.  The  heavy  wines  are, 
in  general,  too  sweet  for  the  use  of  sick 
persons;  when  obtained  "dry"  (free,  or 
nearly  free,  from  sugar),  however,  they 
are  frequently  of  benefit  to  convales- 
cents and  to  the  debilitated. 

The  light  wines  contain  from  5  to  15 
per  cent,  of  alcohol.  Ordinary  claret 
ranges  from  6  to  12  per  cent.  This 
group  also  includes  Burgundy,  the  Rhine 
wines.  Moselle,  Tokay,  champagne,  and 
hock,  in  all  of  which  the  percentage  of 
alcohol  is  usually  between  9  and  14. 
Champagne,  though  it  contains  only 
about  10  per  cent,  of  alcohol,  has  a  pro- 
nounced stimulating  effect  on  the  gastric 
mucous  membrane  because  of  the  large 
amount  of  carbon  dioxide  it  liberates. 
Wines  are  more  slowly  absorbed  than 
alcohol,  and  the  physiological  effects  of 
the  alcohol  they  contain  are  correspond- 
ingly less  marked.  In  addition,  wines 
possess  distinct  nutritive  value,  by  vir- 
tue of  the  numerous  substances,  both 
organic  and  mineral,  which  they  em- 
body. These  include,  according  to  an 
analysis  of  red  wine  by  Gautier,  albu- 
minoid, fatty,  and  carbohydrate  constit- 
uents, glycerin,  potassium  tartrate^  suc- 


cinic acid,  acetic,  citric,  malic  and 
carbonic  acids,  and  salts  such  as  the 
chlorides,  bromides,  iodides,  fluorides, 
and  phosphates  of  potassium,  sodium, 
calcium  and  magnesium  oxide  of  iron, 
etc.  Wine  also  contains  a  number  of 
volatile  bodies,  such  as  are  present  in 
brandy  in  larger  amount.  Light  wines 
are  useful  wherever  prostration  is  or 
has  been  a  marked  feature  of  the  case, 
e.g.,  in  typhus,  intermittent  fever, 
scurvy,  and  cholera  among  the  more 
acute  diseases ;  also  in  many  chronic  af- 
fections, excluding,  however,  cases  of 
Bright's  disease,  chronic  digestive  dis- 
orders, neurasthenia,  anemia,  and  dia- 
betes. Wines  are  peculiarly  liable  to 
undergo  acetic  fermentation  in  the 
stomach  (Hayem),  and  hence  are  not 
well  borne  in  certain  gastric  dis- 
turbances. It  has  been  found  in 
vitro  that  wines  uniformly  interfere 
with  peptic  digestion.  Red  wines 
very  usually  disagree  where  there 
is  gastric  hyperacidity.  In  these 
cases  white  wines  are  generally  service- 
able. White  wines  have  a  diuretic  ef- 
fect beyond  that  possessed  by  the  red 
wines.  When  very  acid,  however,  they 
are  in  themselves  capable  of  causing 
gastric  disorders,  and  should  be  avoided 
wherever  diarrhea  exists!  Many  of  the 
Rhine  wines  are  not  suited  to  those 
having  a  tendency  to  the  formation  of 
oxalic  deposits,  owing  to  the  oxalic  acid 
which  they  contain. 

Malt  liquors  (beer,  ale,  brown  stout, 
porter)  contain  less  alcohol  but  have 
greater  nutritive  value  than  any  other 
of  the  alcoholic  beverages.  They  are 
produced  by  causing  an  extract  of  malt 
(sprouted  barley  grains)  and  hops  to 
undergo  fermentation  by  the  yeast- 
plant.  The  malt  is  previously  allowed 
to  germinate,  in  order  that  the  starch  it 
contains  shall  be  transformed  into  the 


510 


ALCOHOL    (SAJOUS). 


more  easily  fermentable  sugar.  The 
diastase  which  effects  this  conversion  is 
formed  by  the  grain  itself  during  germi- 
nation. The  yeast  then  ferments  the 
sugar  with  the  production  of  alcohol. 
The  final  product  contains  about  3  to  7 
per  cent,  of  alcohol  and  a  large  percent- 
age of  solid  constituents  available  for 
nutrition,  including  mainly  dextrin, 
sugar;  albuminoid,  fatty  and  gummy 
substances ;  succinic!^  lactic  and  acetic 
acids;  aromatic  and  bitter  principles 
derived  from  the  hops,  carbon  dioxide 
to  the  extent  of  6  to  8  times  the  volume 
of  the  liquor,  and  a  number  of  salts  re- 
sembling those  found  in  the  ashes  of 
meat  extract,  principally  phosphates  and 
salts  of  potassium  and  calcium  (Man- 
quat).  Beers  also  contain  diastase, 
which  aids  in  the  digestion  of  carbohy- 
drate foods  and  tends  to  produce 
obesity.  Ale  differs  from  beer  in  that 
its  fermentation  is  carried  on  at  a  high 
temperature  instead  of  a  low  one;  it 
usually  has  a  higher  percentage  of 
alcohol,  ranging  from  4  to  8  or  9  per 
cent.,  while  beer  has  2  to  6  per  cent.  (4 
per  cent,  on  the  average).  Porter  and 
brown  stout  are  fermented  at  a  still 
higher  temperature ;  some  of  the  sugar 
is  converted  to  caramel,  giving  these 
beverages  their  darker  color.  They 
contain  4  to  6  per  cent,  of  alcohol. 

When  the  digestive  powers  are  but 
little  impaired,  beer  is  valuable  as  a 
tonic  and  nutritive.  The  hops  and  the 
carbon  dioxide  probably  both  stimulate 
functionally  the  gastric  mucosa.  Where 
the  digestion  is  weak,  the  large  dextrin 
and  sugar  content  of  beer  may  undergo 
fermentation  in  the  stomach.  The  ab- 
sorption of  beer  is,  in  any  case,  slower 
than  that  of  other  liquors.  Beer  diluted 
with  water  is  said  to  be  better  borne 
than  wines  where  there  is  hyperchlor- 
hydria.     The  low  percentage  of  alcohol 


contained  in  beer  renders  it  useful 
where  the  patient  appears  specially 
sensitive  to  the  action  of  alcohol  on  the 
cerebrum.  A  syrupy  extract  of  malt  is 
official  in  the  United  States  Pharma- 
copeia as  extractum  malti;  it  contains 
large  proportions  of  dextrin,  sugar, 
phosphates  and  nitrogenous  bodies,  and 
but  2  per  cent,  of  alcohol. 

Less  important  medically  are  the 
wines  of  other  fruits  than  the  grape, 
and  the  liqueurs.  Among  the  former 
may  be  mentioned  cider,  which  results 
from  the  fermentation  of  apples  and 
contains  2  to  5  per  cent,  of  alcohol,  and 
perry,  a  similar  product  made  from 
pears.  Cider  is  useful  where  diuretic 
and  slightly  laxative  effects  are  desired. 
Liqueurs  comprise  a  large  class  of 
alcoholic  products  differing  widely  in 
composition.  They  are  generally  made 
by  the  addition  of  essential  oils ;  they 
frequently  contain  a  large  amount  of 
sugar,  and  are  of  but  little  value  in 
therapeutics. 

In  acute  diseases  alcohol  is  usually 
given  internally  in  the  form  of  whisky 
or  brandy. 

CONTRAINDICATIONS.— Al- 
cohol is  contraindicated  in  nephritis  and 
inflammatory  conditions  of  the  urinary 
passages,  in  conditions  associated  with 
marked  gastric  or  intestinal  irritation, 
and  in  persons  likely  to  acquire  the 
alcoholic  habit, — especially  young  adult 
or  middle-aged  neurotics,  and  persons 
who  have  been  subjected  to  traumatism 
of  nervous  structures.  In  prolonged 
cardiac  depression  alcohol  is  likely  to 
do  more  harm  than  good.  Sweet  wines 
and  beer  are  contraindicated  in  diabetes 
mellitus  and  in  eczema.  In  the  diar- 
rheas of  children  alcohol  should  not  be 
administered  unless  the  stomach  and 
bowels  have  already  been  freed  from 
putrefying  material. 


ALCOHOL    (SAJOUS). 


511 


Protest  against  alcoliol  in  any  form 
in  ptosis  of  the  stomach  or  intestines, 
as  this  is  not  a  local  affection,  but  is 
associated  with  nervous  and  other 
disturbances.  The  physical  and  nerv- 
ous disturljances  which  forbid  the  use 
of  alcohol  in  cases  of  enteroptosis  in 
many  cases  do  not  develop  until  the 
age  of  25  to  28.  Concussion  of  the 
brain  contraindicates  alcohol;  many 
physicians  refuse  to  treat  traumatic 
nervous  affections  unless  the  patients 
go  to  a  hospital  where  abstention 
from  alcohol  will  be  enforced.  Trau- 
matic nervous  affections  tend  to  in- 
duce hysteria,  and  the  necessity  for 
abstention  from  alcohol  in  hysteria 
and  neurasthenia  and  conditions  of 
dread  and  compulsion  can  never  be 
too  often  emphasized.  The  patient 
is  chained  to  his  crutch  and  soon  is 
unable  to  do  without  it  if  alcohol  is 
given  to  relieve  him.  A  psychic 
trauma  of  any  kind  should  contraindi- 
cate  alcohol,  as  it  is  particularly  liable 
to  act  abnormally  in  abnormal  psy- 
chic conditions.  This  includes  the 
period  before  and  after  an  operation. 
Abstention  from  alcohol  is  an  impor- 
tant factor  in  the  warding  ofif  of  the 
after-affection  of  gonorrhea  and  syph- 
ilis. The  worst  forms  of  tabes  occur 
among  those  who  take  alcohol,  and 
the  lesser  consumption  of  alcohol  is 
one  reason  why  women  have  the 
milder  form.  Among  the  injurious 
influences  of  syphilis  must  be  counted, 
besides  the  virus,  the  emotional  dis- 
tress, the  knowledge  of  the  disease, 
the  psychic  depression  and  the  neces- 
sity for  secrecy,  all  of  which  render 
alcohol  particularly  injurious  for 
syphilitics.  Roder  (Med.  Klinik,  Nov. 
8, 1908). 

Syphilis  is  always  badly  affected  by 
alcohol,  and  the  latter  is  responsible 
for  many  of  the  evil  results  often 
seen  in  this  disease,  both  in  the  skin 
and  in  the  nervous  system.  The 
syphilitic  should  be  an  abstainer  from 
alcohol  from  the  moment  of  his  infec- 
tion. Acne  constantly  shows  the 
effect  of  drinks  containing  alcohol, 
the  condition  varying  more  or  less 
according    to    the    character    of    the 


beverage.  The  acne  rosacea  of  tip- 
plers is  well  known,  and  this  is  often 
followed  by  a  permanent  dilatation  of 
the  capillaries  of  the  face  and  hyper- 
trophy of  the  nose,  resulting  even  in 
rhinophyma.  In  beer  and  ale  drink- 
ers the  eruption  is  of  a  more  pustular 
character,  often  with  large  •  lesions. 
Eczema  is  often  profoundly  affected 
by  alcoholic  beverages,  which  might 
render  the  disease  incurable  when 
they  are  persisted  in,  even  in  mod- 
eration. Psoriasis  is  greatly  aggra- 
vated by  the  indulgence  in  alcoholics 
and  is  caused  to  itch  by  such  indul- 
gences; the  use  of  alcohol  can  also 
induce  a  fresh  attack  after  a  long 
period  of  freedom  from  the  eruption. 
In  cases  of  even  moderate  drinkers 
the  disease  yields  much  more  quickly 
under  total  abstinence.  L.  Duncan 
Bulkley  (Med.  Rec,  Jan.  29,  1910). 

PHYSIOLOGICAL    ACTION.— 

The  effects  of  alcohol,  when  it  is  taken 
internally,  vary  according  to  the  size  of 
the  dose.  The  action  here  to  be  de- 
scribed is  that  of  therapeutic  or  some- 
what larger  doses. 

Digestive  Tract. — In  the  mouth 
and  pharynx,  alcohol  has  a  slightly 
astringent  action  upon  the  mucous 
membranes.  For  a  brief  period  it  also 
causes  an  increased  flow  of  saliva,  and 
when  in  no  greater  concentration  than  5 
per  cent.,  has  been  found  by  Storck  to 
favor  the  digestion  of  starchy  foods  by 
ptyaHn.  The  action  of  ptyalin  is,  on 
the  contrary,  unfavorably  influenced  by 
alcohol  in  10  per  cent,  strength  and, 
more  particularly,  by  the  acids  con- 
tained in  malt  beverages  and  wines. 

On  reaching  the  stomach,  alcohol 
produces  a  sense  of  warmth,  which  is 
promptly  followed,  as  absorption  takes 
place,  by  a  general  feeling  of  well-being 
and  restfulness.  When  present  in  the 
stomach  in  small  amount  only,  alcohol 
has  no  marked  effect  on  peptic  diges- 
tion, and  often  distinctly  augments  the 


512 


ALCOHOL    (SAJOUS). 


secretion  of  gastric  juice,  itself  becom- 
ing thereby  progressively  more  dilute. 
It  acts  both  by  stimulating  directly  the 
gastric  circulation  and  the  secreting 
cells  to  greater  activity,  and  probably 
also  by  a  special  secretory  influence  of 
the  alcohol  after  its  absorption.  Since 
Spiro,  Frouin  and  Moulinier  observed 
that  alcohol  administered  per  rectum 
caused  in  the  stomach  a  marked  flow  of 
abnormally  acid  gastric  juice.  Chitten- 
den and  Mendel  showed,  moreover,  that 
the  relative  amounts  of  pepsin  and 
hydrochloric  acid  in  the  gastric  juice 
were  both  increased.  Thus  alcohol  in 
small  quantities  tends  to  hasten  gastric 
digestion.  Fatty  substances  being  dis- 
solved by  it,  their  absorption  is  facili- 
tated. The  appetite,  when  poor,  is 
improved. 

When  5  to  10  per  cent,  of  alcohol  is 
present,  peptic  digestion  takes  place 
less  rapidly  than  normal,  the  degree  of 
interference  varying  with  the  kind  of 
food  to  be  acted  upon.  According  to 
Klemperer  and  Battelli,  however,  gastric 
motility  is  hastened  by  moderate 
amounts  of  alcohol,  while  Bandl,  Scan- 
zoni  and  others  have  shown  that  liquids 
containing  alcohol  are  much  more 
rapidly  absorbed  from  the  stomach 
than  liquids  free  of  it.  It  thus  happens 
in  many  cases  that  the  interference  of 
the  alcohol  with  peptic  digestion  is  more 
than  counterbalanced  by  the  hastened 
absorption  as  well  as  by  the  increased 
amount  of  gastric  juice.  Gluzinsky's 
experiments  indicate  that  alcohol  slows 
gastric  digestion  only  during  the  period 
before  its  absorption;  it  then  causes  in- 
creased rapidity  of  digestion  because  of 
the  special  stimulating  effect  on  secret- 
ing structures  already  mentioned.  Ac- 
cording to  this  author  60  Gm.  (about 
2  fluidounces)  of  cognac,  taken  during 
or  before  a  meal,  slows  the  digestion  of 


carbohydrates  and  hastens  that  of 
meats,  but  when  taken  after  the  meal 
hinders  both.  It  has  been  noticed  that 
spirits  are  much  less  potent  in  hamper- 
ing peptic  activity  than  are  wines  and 
especially  malt  liquors. 

Series  of  experiments  to  determine 
the  influence  of  alcohol  upon  the  se- 
cretion of  the  gastric  juice:  upon  a 
case  of  gastroptosis,  one  of  hysteria, 
one  of  atony  of  the  stomach,  after 
gastro-enterostomy,  and  one  of  gas- 
tro-enteritis.  The  alcohol  was  admin- 
istered per  rectum,  and  the  patient 
took  no  nourishment  by  the  mouth. 
It  was  found  that  the  enema  caused 
an  active  secretion  of  gastric  juice 
provided  the  amount  of  alcohol  was 
not  less  than  7  to  10  c.c.  The  acidity 
reached  its  maximum  about  an  hour 
after  the  injections,  and  then  grad- 
ually decreased.  In  two  cases  of 
achylia  due  to  carcinoma  of  the  stom- 
ach no  effect  was  observed.  R.  Spiro 
(Miinch.  med.  Woch.,  No.  47,  1901). 

Alcohol  passes  quickly  from  the 
stomach  into  the  intestines.  Here  also 
it  is  absorbed,  and  exerts,  when  in 
small  amount,  an  effect  similar  to  that 
produced  on  the  stomach,  viz.,  stimu- 
lates the  mucous  and  other  glands  to 
increased  activity.  Relaxation  of  the 
bowels  and  meteorism  are  frequently 
influenced  by  it.  In  vitro  alcohol  in  3 
per  cent,  strength,  "however,  slows  the 
digestion  of  proteids  by  the  pancreatic 
juice   (Chittenden  and  Mendel). 

Nervous  System. — When  the  ac- 
tion of  alcohol  has  been  exerted  long 
enough,  it  acts  as  a  depressant  to  the 
nervous  system.  The  effects  seen  at 
first  suggest  primary  cerebral  stimula- 
tion, but  it  is  a  question  whether  these 
phenomena  are  not  really  the  result  of 
impaired  inhibition,  in  which  case  alco- 
hol might  be  said  to  act  as  a  depressant 
from  the  beginning.  Small  amounts  of 
alcohol  do,  indeed,  produce  effects  sug- 


ALCOHOL    (SAJOUS). 


513 


gesting  loss  of  inhibitory  control  over 
cerebral  activities,  though  it  must  be 
admitted  that  the  actual  physiological 
existence  of  such  a  controlling  function 
has  not  yet  been  definitely  proved.  In 
the  primary  stage  of  apparent  excita- 
tion, the  subject  exhibits  loss  of  con- 
trol, as  manifested  by  loose  speech, 
laughter  upon  slight  provocation,  out- 
bursts of  the  passions  and  exaggerated 
movements.  The  subject  becomes  self- 
ish, irresponsible,  and  lacks  will-power. 
Bunge,  Schmiedeberg  and  others  be- 
lieve that  these  phenomena  occur  be- 
cause the  normal  inhibitory  influence 
on  the  cortical  centers  has  been  reduced. 
As  an  argument  against  the  theory 
of  primary  stimulation  it  is  pointed  out 
that  a  primary  stage  of  excitement  is 
usually  not  seen  when  the  subject  re- 
mains in  quiet  and  dark  surroundings 
after  taking  alcohol,  while  certain  indi- 
viduals show  no  evidences  of  stimula- 
tion under  any  circumstances,  but  soon 
pass  into  a  state  of  cerebral  depression. 
Other  observers  believe  that  the  physi- 
cal excitement  and  the  unusual  flow  of 
ideas  and  powers  of  speech  often  ob- 
served under  the  influence  of  alcohol 
indicate  a  primary  stimulating  effect  on 
the  same  centers.  The  ability  to  per- 
form muscular  work  has  usually  been 
found  in  experiments  to  be  increased 
for  a  brief  period  by  alcohol  in  small 
amounts,  especially  where  fatigue  ex- 
ists, but  this  is  very  promptly  followed 
by  a  distinct  decrease ;  further,  it  is  not 
proven  that  the  preliminary  increase  is 
due  to  excitation  of  the  motor  areas, 
since  the  nerves  or  muscles  themselves 
may  instead  have  been  affected.  Krae- 
pelin  concluded  from  his  experiments 
that  motor  activities  were  heightened 
by  alcohol  in  small  amounts  and  de- 
pressed by  larger  quantities,  but  that 
the  mental  activities  were  lowered  for 


a  period  of  twelve  to  twenty-four 
hours  by  it  even  in  small  doses.  Alco- 
hol acts  also  on  certain  sensory  centers, 
reducing  pain. 

After  taking  small  amounts  of  alco- 
hol there  is  an  apparent  temporary  in- 
crease of  brain-activity,  which  is  but 
an  evidence  of  the  paralyzing  and 
deleterious  effect  of  alcohol.  It  de- 
stroys the  special  function  of  the 
cerebellum,  and  produces  tremor  and 
weakness  of  the  lower  limbs.  In 
chronic  alcoholism  the  dendrites  oi 
the  pyramidal  nerve-cells  show  swell- 
ings and  shrinkages,  and  there  is  wide- 
spread pigmentation  in  the  nerve- 
cells.  Even  small  doses  of  alcohol  at 
meals  have  a  deleterious  influence, 
and  total  abstinence  must  be  the 
course  of  those  who  wish  to  follow 
the  plain  teaching  of  truth.  Victor 
Horsley  (Lancet,  May  5,  1900). 

With  our  present  knowledge  it  may 
be  said  that  alcohol  furnishes  energy 
for  muscular  work  in  the  same  man- 
ner as  fats  and  carbohydrates.  There 
is  no  reason  for  believing  that  the 
muscle-cells  cannot  burn  alcohol  as 
they  do  other  foodstuffs.  However, 
from  the  standpoint  of  ability  to  do 
strenuous  muscular  work,  there  is  evi- 
dence that  a  man  cannot  do  as  much 
work  in  the  long  run  with  alcohol  as 
with  carbohydrates.  Mountain-climb- 
ers and  athletes  cannot  do  their  best 
work  when  alcohol  forms  a  part  of 
their  diet.  This  effect  is  explained  by 
the  drug  action  of  alcohol  upon  the 
nervous  system.  Scarbrough  (Yale 
Med.  Jour.,  Feb.,  1910). 

Tests  carried  out  on  himself  by  the 
author  through  a  number  of  months 
to  determine  the  influence  of  a  small 
amount  of  liquor  on  the  power  of 
concentrating  the  attention  on  and 
remembering  twenty-five  lines  of  a 
translation  of  the  Odyssey,  the  blank 
verse  being  especially  adapted  for 
such  tests.  The  alcohol  had  an  un- 
mistakable influence  in  reducing  the 
powers  of  perception,  and  this  efifect 
was  twice  as  marked  on  a  fasting 
stomach.  Vogt  (Norsk  Mag.  f.  Lae- 
gevidenskaben,  June,  1910). 


1—33 


514 


ALCOHOL    (SAJOUS). 


After  the  initial  stage  of  apparent 
stimulation,  the  actual  depressant  action 
of  alcohol  on  the  nervous  system  is  no 
longer  in  doubt.  Soldiers  have  been 
found  to  march  better  and  remain 
stronger  without  alcohol  than  when 
supplied  with  it  in  moderate  amounts. 
Large  single  doses  produce  signs  of  dis- 
tinct brain  depression,  passing  from 
muscular  inco-ordination,  with  imper- 
fect speech,  impaired  sensibility,  and 
somnolence,  to  a  state  of  unconscious- 
ness similar  to  that  of  ether  and  chloro- 
form anesthesia.  The  spinal  cord  is 
depressed  by  alcohol  even  before  the 
unmistakable  signs  of  cerebral  depres- 
sion occur,  as  shown  by  the  early 
muscular  inco-ordination  (apart  from 
disturbances  of  equilibrium)  and  dimin- 
ished reflex  irritability.  The  functions 
of  the  bulbar  centers,  however,  are  not 
markedly  affected  until  late.  On  the 
peripheral  nerves  alcohol  in  large  doses 
was  found  by  Dogiel  to  exert  a  pro- 
nounced depressing  effect  in  dogs. 
Motor  nerves  are  believed  to  withstand 
this  effect  longer  than  sensory  nerves. 
In  the  frog  the  response  of  the  motor 
nerves  to  stimuli  is  at  first  increased 
when  the  vapor  of  alcohol  is  brought  in 
contact  with  it,  but  the  usual  depressant 
action  soon  follows. 

Circulation. — Although  the  pulse- 
rate  is  commonly  increased  after  the 
use  of  alcohol  in  considerable  amount, 
Jacquet  believes  that  where  the  subject 
can  be  kept  free  from  external  exciting 
influences,  no  such  change  in  the  heart- 
action  is  produced.  The  results  of  ex- 
periments intended  to  develop  the  action 
of  alcohol  on  the  heart  have  been  con- 
tradictory. It  is  thought  by  many  that 
the  mammalian  heart  is  slightly  stimu- 
lated by  alcohol  unless  given  in  large 
amounts,  when  it  is  depressed  (Dixon 
and  Bachmann,  Wood  and  Hoyt,  Loeb, 


Bachen).  Alcohol  in  2  per  cent. 
strength  passed  through  the  coronaries 
of  a  cat's  heart  does  not  cause  ari-est 
of  cardiac  activity  (Loeb).  Other 
experimenters  conclude  that  alcohol 
causes  no  increase  in  the  work  per- 
formed by  the  heart.  According  to 
Cushny  the  preliminary  action  of  alco- 
hol is  to  weaken  the  heartbeats.  As 
for  the  blood-pressure,  moderate  doses 
have  usually  not  been  found  to  alter  it. 
The  advocates  of  primary  cardiac 
stimulation  by  alcohol  account  for  this 
by  the  dilatation  of  the  peripheral 
blood-channels,  which  is  often  manifest 
in  the  flushed  face,  injected  conjunc- 
tivje,  and  heated  skin  surfaces  observed 
after  the  use  of  alcohol.  The  speed 
with  which  the  blood  courses  through 
the  vessels  is  thereby  increased  (Hem- 
meter,  Wood  and  Hoyt).  Whether  the 
vascular  dilatation  is  due  to  an  action 
on  the  vasomotor  centers  or  on  the 
vessels  themselves  has  not  as  yet  been 
determined.  The  results  include  dis- 
turbances in  the  cerebral  circulation; 
the  brain  may  be  the  seat  either 
of  marked  hyperemia  or  of  anemia 
(Claude  Bernard).  Certain  experi- 
menters have  at  times  observed  in- 
creased blood-pressure  due  to  alcohol; 
thus  Kochmann  noted  in  man  a  rise  in 
the  pressure  upon  the  exhibition  of  5 
to  10  c.c.  (1^  to  2y2  drams)  of  abso- 
lute alcohol.  Such  an  elevation  of 
pressure  might  be  due  either  to  a  direct 
stimulating  effect  on  the  vasomotor 
centers,  or,  as  many  believe,  to  a  reflex 
effect  on  these  centers  due  to  irritation 
of  the  gastrointestinal  mucous  mem- 
branes. 

The  contact  of  strong  alcohol  with 
the  mucous  membranes  of  the  mouth, 
esophagus,  and  stomach  acts  reflexly 
through  the  medulla  to  cause  vaso- 
constriction, which  raises  the  blood- 
pressure,    and    hence    stimulates   the 


ALCOHOL    (SAJOUS). 


515 


heart.  After  alcohol  is  absorbed  (it 
circulates  as  alcohol)  it  causes  vaso- 
dilation and  a  fall  in  blood-pressure. 
It  is  certain  that  overdoses  of  alcohol 
after  absorption  are  depressant  to  the 
heart-muscle,  to  the  muscle-fibers  of 
the  blood-vessel  walls,  and  to  the 
vasomotor  center  in  the  medulla.  On 
these  considerations  the  author  bases 
his  advice  on  the  use  of  alcohol  in 
derangenients  and  affections  of  the 
heart.  With  regard  to  the  utility  of 
alcohol  in  combating  poisons  circulat- 
ing in  the  blood,  clinical  experience  is 
not  conclusive.  Laboratory  experi- 
ments should  be  undertaken  in  order 
to  settle  this  point.  O.  T.  Osborne 
(Jour.  Amer.  Med.  Assoc,  Dec.  5, 
1903). 

Experiments  performed  in  rabbits, 
supporting  the  belief  that  the  accel- 
eration of  the  heart  after  the  use  of 
alcohol  is  a  gastric  reflex  from  irrita- 
tion, and  that  when  the  reflexes  have 
been  abolished  as  a  result  of  the  an- 
esthesia, the  quickening  of  the  heart 
and  the  subsequent  rise  in  pressure 
from  alcohol  do  not  occur.  A  simi- 
lar effect  upon  the  circulatory  system 
can  be  produced  by  other  gastric  ir- 
ritants, such  as  ammonia,  ether,  and 
capsicum.  McNider  (Charlotte  Med. 
Jour.,  Aug.,  1909). 

Report  concerning  a  series  of  mano- 
metric  blood-pressure  tracings  show- 
ing the  effect  of  alcohol  on  dogs  not 
under  the  influence  of  any. anesthetic. 
The  primary  action  of  alcohol  was 
found  to  vary  according  to  the  mode 
of  administration:  By  mouth  it 
caused  a  marked  rise  in  blood-press- 
ure, with  increased  amplitude  and  a 
constant,  or  slightly  slowed  rhythm 
of  heartbeat.  This  rise  gradually 
passed  off  in  five  or  ten  minutes.  In 
some  instances,  at  the  time  of  pour- 
ing the  alcohol  into  the  dog's  throat, 
and  just  preceding  the  rise  mentioned, 
there  was  a  sudden  drop  and  almost 
immediate  recovery  of  blood-pressure. 
When  given  intravenously  alcohol 
caused  a  sharp  drop  in  blood-pressure, 
during  which  the  heart  was  greatly 
slowed  or  almost  stopped;  but  very 
soon,  unless  the  dose  was  too  large. 


there  followed  a  rapid  recovery.  Upon 
administration  of  alcohol  by  gastric 
fistula  there  was  no  specific  primary 
action.  By  whatever  method  admin- 
istered, alcohol,  when  circulating  in 
the  blood-stream,  causes  a  gradual, 
pfogressive  lowering  of  blood-press- 
ure with  decrease  in  amplitude,  but 
increase  in  rate  of  heartbeat.  Clyde 
Brooks  (Jour.  Amer.  Med.  Assoc, 
July  30,  1910). 

Excessive  amounts  of  alcohol  cause 
a  pronounced  fall  in  the  bloocl-pressure, 
since  they  depress  both  the  heart  and 
the  vasomotor  center.  They  have  also 
been  observed  in  animals  to  slow  the 
heart  action,  and  even  produce  cardiac 
arrest,  in  much  the  same  manner  as 
does  chloroform.  According  to  Pou- 
chet,  the  secondary  fall  of  blood-press- 
ure is  due  largely  to  stimulation  of  the 
inhibitory  pneumogastric  centers ;  the 
pressure  may,  indeed,  at  a  certain  stage 
of  the  poisoning  be  brought  almost  back 
to  normal  by  section  of  the  vagi. 

Retardation  of  the  pulse  is  brought 
about  by  an  irritation  of  the  vagus 
centers,  and  of  the  peripheral  ends  of 
the  vagi,  in  part  due  to  a  direct  car- 
diac action.  The  fall  in  blood-press- 
ure is  due  to  a  direct  injurious  influ- 
ence upon  the  heart-muscle.  Ladislas 
Ilaskovec  (Wiener  med.  Blatter,  Oct. 
11,1900). 

Experiments  to  determine  whether 
alcohol,  coming  in  direct  contact  with 
the  heart  muscle,  would  act  as  a 
stimulant  to  the  action  of  that  mus- 
cle or  not.  The  author  feels  justified 
in  concluding  that  alcohol  is  not  a 
stimulant  to  heart  muscle,  but  rather 
a  depressant  and  a  poison.  A.  W. 
Downs  (Monthly  Cyclo.  and  Med. 
Bull.,  March,  1911). 

Blood. — Large  amounts  of  alcohol 
must  be  present  to  cause  perceptible 
changes  in  the  blood  in  a  short  space  of 
time.  Foguet  claimed  to  have  ascer- 
tained that  intoxicating  doses,  taken 
daily,    were    without    efifect.      Pouchet 


516 


ALCOHOL    (SAJOUS). 


states,  however,  that  tinder  small,  re- 
peated doses,  the  blood  gradually  under- 
goes fatty  changes,  owing  to  the  fact 
that  the  emulsified  fats  entering  the 
blood  with  the  chyle  are  not  consumed 
as  normally.  At  the  same  time  the 
alkalinity  of  the  blood  is  lowered,  the 
coagulabihty  rises,  and  a  process  of 
dehydration  goes  on,  as  shown  by  diure- 
sis and  increased  secretions  generally, 
whereby  the  blood  becomes  relatively 
more  concentrated,  the  erythrocyte 
count  and  hemoglobin  percentage  ris- 
ing. Schmiedeberg  found  that  blood 
containing  alcohol  loses  in  part  its 
oxygenating  power, — a  fact  of  con- 
siderable practical  significance.  In 
vitro,  alcohol  added  to  blood  darkens  its 
color,  coagulates  it,  and  causes  hemo- 
globin to  leave  the  erythrocytes.  Such 
effects  can  only  be  obtained  in  the 
animal  organism  by  the  intravenous  in- 
jection of  alcohol  in  large  doses.  Under 
these  conditions  the  red  cells  undergo 
marked  changes  in  shape  and  color 
(Hayem).  The  fats  a-nd  lecithin  are 
dissolved,  and  the  hemoglobin  becomes 
dissociated  from  .the  stroma  and  pre- 
cipitated in  reddish,  refractile  droplets. 
Bordet  and  Massart  showed  alcohol  to 
have  a  strong  negative  chemotactic  in- 
fluence on  the  white  blood-cehs,  even 
when  greatly  diluted. 

Microscopic  changes  in  the  tissues 
as  a  result  of  alcohol,  taken  from  ob- 
servations on  animals:  L  The  most 
marked  effects  are  produced  on  the 
blood-vessels.  2.  The  cells  which 
line  the  vessels  are  swollen  and 
broken,  and  there  are  serious  retro- 
grade changes  in  all  of  the  tissues. 
The  white  blood-cells  become  swol- 
len and  necrotic.  3.  The  lymph- 
spaces  become  choked  with  broken- 
down  white  blood-cells,  and  the  small 
blood-vessels  are  also  completely 
blocked  by  plugs  in  detritus  and  dead 
tissue.     4.  In  the  veins  the  blocking 


is    often    so    severe    that    the   vessels 
burst  from  the  backing  up  of  blood  in 
them.     The  changes  are  always  more 
marked   in    the   vessels    of   the   brain 
than  elsewhere  because  they  do  not 
possess  the  special  nerves  which  con- 
trol  their   caliber,  as    do   the  vessels 
of    other   parts    of   the   body.      H.   J. 
Berkley  (Johns  Hopkins  Hosp.  Bull.; 
Amer.  Jour,  of  Physiol.  Therap.,  May, 
1910). 
Respiration.  —  Volumetric     estima- 
tions made  before  and  after  the  inges- 
tion of  alcohol  have  shown  fairly  con- 
clusively that,   even  in  the  absence  of 
motor  excitement,  the   drug  causes  an 
increase  in  the  amount  of  air  breathed. 
Usually  the  augmentation  is  more  pro- 
nounced    in     fatigued     or     exhausted 
individuals.    Considerable  experimenta- 
tion has  been  indulged  in  for  the  pur- 
pose of  ascertaining  whether  the  drug 
stimulates  directly  the  respiratory  cen- 
ters   in    the    medulla    or    whether    the 
effect  is  of  indirect  origin,  viz.,  through 
irritation  of  the  gastric  mucosa.    Thus 
Loewy  conducted  experiments  in  which 
the  irritability  of  the  centers  of  respira- 
tion before  and  after  the  use  of  alcohol 
was  ascertained  through  its  response  to 
an  increase   of   carbon  dioxide  in   the 
blood.     The  results  of  these  and  other 
researches  have  not  been  entirely  con- 
clusive, but,  in  a  general  way,  they  tend 
to  show  that  alcohol  exerts,  in  man  at 
least,  little  if  any  direct  central  stimula- 
tion, and  therefore,  that  the  improve- 
ment in  respiration  observed  under  the 
influence  of  therapeutic  doses  of  alco- 
hol is  probably  due  to  a  reflex  effect  on 
the  centers.    An  additional  argument  in 
favor  of  the  latter  view  is  in  the  fact 
that  respiratory  depression  occurs  only 
under  exceedingly  large  doses  of  alco- 
hol and  at  a  late  stage  in  the  poisoning, 
tending  to  show  that  the  effect  of  this 
drug  on  the  respiratory  centers  is,  under 
ordinary    circumstances,    not    a    very 


ALCOHOL    (SAJOUS). 


517 


marked  one.  Yet  it  is  well  known  that 
in  the  final  stage  of  acute  alcoholic 
poisoning  the  breathing  becomes  more 
and  more  shallow  and  infrequent,  com- 
plete arrest  ultimately  occurring. 

In  fever,  both  the  respiration  and  the 
heart-rate  are  slowed  by  alcohol.  This 
seems  reasonably  accounted  for  by  a 
lessening  of  general  bodily  excitement 
through  the  narcotic  action  of  alcohol, 
without  implicating  a  direct  depressing 
action  of  moderate  doses  of  it  upon 
both  the  respiratory  centers  and  heart. 

Secretions. — A^Eany  of  the  secre- 
tions are  to  a  certain  extent  activated 
by  alcohol.  The  saliva  and  digestive 
secretions  are  increased  reflexly  by  the 
local  action  of  alcohol  on  the  mucous 
membranes,  as  well  as,  probably,  after 
its  absorption,  through  direct  contact  of 
alcohol  with  the  gland-cells  as  the  drug 
circulates  with  the  blood-stream.  The 
sweat  secretion  is  increased  owing  to 
the  peripheral  vasodilatation.  The 
urine  is  also  augmented.  The  question 
whether  a  direct  exciting  action  on  the 
renal  epithelium  is  exerted  or  not  has  not 
yet  been  settled,  though  the  fact  that 
albuminuria  may  result  from  excessive 
doses  would  seem  to  point  to  an  irrita- 
tive effect  on  the  kidney  cells.  - 

Temperature. — Alcohol  in  ordinary 
doses  causes  a  slight  fall  in  the  body 
temperature  (}4°  to  1°  C,  according  to 
Cushny),  owing  to  the  dilatation  of  the 
superficial  blood-vessels,  which  exposes 
a  larger  amount  of  blood  to  the  cooling 
influence  of  the  surrounding  air.  At 
the  same  time  a  sensation  of  warmth 
is  experienced,  and  the  temperature  of 
the  skin  may  rise  considerably  owing  to 
its  flushed  condition.  If  a  large  amount 
of  alcohol  be  taken  the  fall  of  mternal 
temperature  may  be  exaggerated  owing 
to  the  complete  motor  inactivity.  The 
§ame  will  occur  under  a  moderate  dose 


of  alcohol  if  the  subject  be  subsequently 
exposed  to  cold. 

Metabolism. — Alcohol  causes  but 
little  change  in  the  oxygen  intake  and 
carbon  dioxide  output,  which,  after  its 
ingestion,  show  no  modification  beyond 
that  to  be  expected  from  any  other  sub- 
stance yielding  energy  to  the  system  by 
oxidation.  Of  course,  if  alcohol  be 
taken  in  amounts  sufficient  to  produce 
sleep,  the  respiratory  gaseous  inter- 
changes will  be  lowered  because  of  the 
muscular  inactivity.  Where  the  drug  is 
taken  repeatedly  in  moderation,  how- 
ever, a  gradual  increase  in  the  oxidizing 
power  of  the  blood  occurs,  apparently 
corresponding  in  amount  to  the  degree 
to  which  tolerance  of  alcohol  has  been 
developed  in  the  individual.  This  fact 
was  well  illustrated  in  the  experiments 
of  Hunt  on  the  toxicity  of  methyl 
cyanide,  a  compound  whose  poisonous 
effect  is  proportional  to  the  extent  to 
which  it  is  oxidized  to  hydrocyanic  acid 
in  the  system.  Animals  given  repeated 
small  doses  of  alcohol,  insufficient  in 
themselves  to  elicit  signs  of  intoxication, 
showed  an  increased  susceptibility  to 
methyl  cyanide,  demonstrating  that  the 
oxidizing  power  of  the  blood  had  be- 
come greater. 

In  addition,  the  administration  of 
alcohol,  which  is  almost  entirely  de- 
stroyed in  the  system  by  oxidation, 
naturally  tends  to  preserve  from  com- 
bustion other  oxidizable  substances 
present — fats  in  particular.  This  ac- 
counts for  the  well-known  fattening 
tendency  of  alcoholic  beverages,  when 
habitually  taken  in  any  but  very  moder- 
ate amounts  (see  section  on  Alcohol  in 
Nutrition). 

Immunity. — As  to  the  influence  of 
alcohol  on  the  powers  of  resistance 
of  the  individual  to  disease,  it  is 
well  known  that  alcoholics  are  less 


518 


ALCOHOL    (SAJOUS). 


resistant  to  acute  infections  and 
more  susceptible  to  dangerous  shock 
from  bodily  injury  than  are  the 
temperate.  Likewise,  animals  given 
alcohol  and  subsequently  inoculated 
with  pathogenic  organisms  or  in- 
jected with  disease  toxins  have  al- 
ways shown  a  low  degree  of  resistance 
as  compared  to  normal  animals.  Del- 
earde  and  Laitinen  in  their  experiments 
found  it  "almost  impossible  to  confer 
immunity  against  rabies,  tetanus,  and 
anthrax  on  alcoholized  animals."  The 
question,  however,  whether  alcohol  in 
the  amounts  in  which  it  has  been  used 
in  the  treatment  of  acute  febrile  dis- 
eases in  non-alcoholics  has  a  similar 
prejudicial  effect  has  not  been  definitely 
settled. 

[Inasmuch  as  the  defensive  power  of 
the  body  fluctuates  with  its  vital  activity, 
beverages  rich  in  alcohol,  besides  inhibit- 
ing the  life  process  itself,  place  it  at  the 
mercy  of  disease-breeding  germs,  and  thus 
actually  help  to  destroy  life  through  de- 
oxidizing or  reducing  action  on  the  blood. 

This  is  further  emphasized  by  the  in- 
fluence of  alcohol  on  the  ductless  glands 
themselves.  While  small  doses  or  weak 
solutions,  as  stated  by  Lorand,  stimulate 
these  organs,  large  quantities  of  beverages 
strong  in  alcohol  cause  their  degeneration, 
as  shown  by  numerous  autopsies.  My 
work  on  the  "Internal  Secretions"  contains 
a  microphotograph  showing  a  pituitary 
body  in  which  alcohol  produced  sclerosis. 
Hertoghe  and  de  Quervain  have  found 
alcohol  harmful  to  the  thyroid — an  organ 
which,  as  is  well  shown  by  cretinism  and 
the  marvelous  effects  of  thyroid  prepara- 
tions in  this  disease,  has  much  to  do  with 
the  development  of  the  body.  The  defen- 
sive functions  of  the  body,  if  carried  on, 
as  I  hold,  by  the  ductless  glands,  are  thus 
directly  hampered  by  the  use  o'f  alcohol  in 
any  but  very  weak  solutions.  This  coin- 
cides with  the  recent  observations  of 
Parkinson,  who  studied  the  influence  of 
alcohol  on  the  autoprotective  functions  of 
the  body.  While  his  experiments  showed 
that  small  quantities  temporarily  enhanced 


the  production  of  antibodies,  as  soon  as 
they  were  replaced  by  large  doses  the 
opsonic  index  fell;  and  if  their  use  was 
continued,  it  remained  low  permanently, 
which  meant  that  the  immunizing  func- 
tions were  paralyzed.  This  confirmed  the 
earlier  experiments  of  Miiller,  Wirgin,  and 
others  referred  to  below. 

It  is  because  of  this  fact  that  drunkards 
in  general  fare  so  badly  in  infectious  dis- 
eases; their  autoprotective  mechanism  is 
powerless  to  defend  them.  Quite  in  accord 
with  these  teachings  of  experience,  Par- 
kinson found  that  the  reaction  to  vaccines 
was  much  less  effective  in  alcoholized  rab- 
bits than  in  normal  rabbits,  and  that  the 
difference  was  still  more  marked  when 
living  micro-organisms  were  used.  Many 
experiments  by  competent  observers  afford 
evidence  'in  the  same  direction.  Again,  I 
have  shown  that  the  immunizing  process 
of  the  body  is  closely  linked  and  runs  on 
parallel  lines  with  oxidation;  since  alcohol 
in  anything  but  small  doses  reduces  oxida- 
tion, it  inhibits  in  proportion  our  power 
to  fight  disease  during  the  active  or  de- 
fensive phase  of  the  morbid  process,  espe- 
cially in  febrile  infections  and  toxemias. 

If  alcohol  is  used  at  all,  therefore,  in 
the  acute  infections  and  toxemias,  it 
should  only  be  given  in  small  quantities 
and  freely  diluted.  But  better  agents  to 
enhance  the  defensive  process  are  now 
available.     C.  E.  de  M.  S.] 

Friedberger,  Muller,  Wirgin,  and 
other  observers  found  that,  in  rabbits, 
the  administration  of  alcohol  for  some 
days  in  amounts  sufficient  to  pro- 
duce a  mild  degree  of  intoxication 
interferes  with  the  formation  of 
antibodies  in  the  blood.  The  greater 
the  time  allowed  to  elapse,  how- 
ever, between  the  injection  of  the 
antigen  and  the  giving  of  alcohol, 
the  less  the  restraining  effect  of  the  lat- 
ter on  the  development  of  protective 
substances.  Experiments  conducted  by 
Laitinen,  in  which  animals  were  given 
for  some  time  doses  of  alcohol  so  small 
as  to  correspond  with  the  amounts 
taken  dietetically  by  moderate  users  of 


ALCOHOL    (SAJOUS). 


519 


alcohol,  did  not  reveal  any  pronounced 
disadvantage  in  the  habitual  use  of 
small  quantities  of  alcohol  as  regards 
susceptibility  to  disease,  the  mortality 
being  but  slightly  greater  than  among 
the  animals  not  given  alcohol. 

Alcohol  in  small  quantities  has  no 
action  on  the  phagocytic  activity,  nor 
has  it  any  action  on  the  phagocytic 
activity  until  it  is  present  in  12.5  per 
cent,  strength.  Small  quantities  of 
alcohol  injected  into  rabbits  may 
stimulate  the  production  of  antibodies 
temporarily.  A  large  dose  lowers  the 
opsonic  index  for  twenty-four  hours. 
Continuous  moderate  doses  cause  a 
permanent  lowering  of  the  opsonic 
index.  The  reacting  mechanism  to 
vaccines  is  mvich  less  effective  in  alco- 
holized rabbits  than  in  normal  rab- 
bits; the  difference  is  still  more 
marked  when  living  micro-organisms 
are  used.  P.  R.  Parkinson  (Lancet, 
Nov.  27,  1909). 

Ingestion  of  alcohol  is  quickly  ac- 
companied by  a  lowered  opsonic  in- 
dex, but  the  index  as  quickly  returns 
to  the  normal  with  cessation  of  the 
alcohol.  The  amount  of  alcohol  needed 
to  bring  about  this  result  had  no  in- 
fluence on  the  resistance  of  the  animal 
to  infection.  Abbott  and  Gildersleeve 
(Univ.  of  Penna.  Med.  Bull.,  June, 
1910). 

Study  of  protein  metabolism  and 
utilization,  and  especially  the  parti- 
tion of  nitrogen  in  the  urine,  under 
the  influence  of  alcohol,  carried  out 
on  man  and  dogs  under  fixed  and 
comparable  conditions  of  diet.  There 
is  no  pronounced  disturbance  in  the 
alimentary  utilization  of  the  food- 
stuffs. Moderate  doses  exert  a  pro- 
tein-sparing action,  which  is  suc- 
ceeded by  loss  of  nitrogen  when 
larger  quantities  of  alcohol  are  ad- 
ministered. The  partition  of  urinary 
nitrogen  remains  remarkably  unal- 
tered, with  the  exception  of  an  in- 
creased elimination  of  ammonia  nitro- 
gen and  a  higher  output  of  purins. 
The  most  significant  impression  af- 
forded was  the  absence  of  pronounced 


alterations  indicative  of  markedly  dis- 
turbed protein  metabolism,  even  when 
comparatively  large  doses  were  con- 
tinued for  days  and  weeks.  Mendel 
and  Hilditch  (Amcr.  Jour,  of  Physiol., 
Nov.,  1910). 

[As  is  the  case  with  all  food  accessories, 
coffee,  tea,  pepper,  common  salt,  etc.,  al- 
cohol becomes  toxic  when  used  immod- 
erately, and  when  insufficiently  diluted. 
Light  wines,  beer,  and  other  beverages 
that  contain  a  very  small  proportion  of 
alcohol,  when  taken  in  moderation,  tend 
to  activate  the  functions  of  the  ductless 
glands,  and,  therefore,  the  autoprotective 
functions  of  the  body.  The  harmful  in- 
fluence of  alcohol  begins  as  soon  as  the 
proportion  of  absolute  alcohol  in  a  bever- 
age exceeds  5  per  cent,  to  any  marked 
degree,  the  toxic  effects  being  due  mainly 
to  its  property  of  becoming  oxidized  at 
the  expense  of  the  blood  and  other  body 
fluids  and  cellular  elements.  When  the 
proportion  exceeds  10  per  cent,  and  ap- 
proximates that  of  brandy,  whisky,  and 
many  patent  or  proprietary  nostrums,  al- 
cohol becomes  an  active  toxic;  it  tends  to 
paralyze  the  functions  of  the  ductless 
glands,  and,  therefore,  the  autoprotective 
functions,  thus  giving  free  sway  to  patho- 
genic germs,  their  toxins  and  other  toxics, 
venoms,  toxic  wastes,  etc.,  that  may  be 
present  in  the  blood,  thus  defeating  in- 
directly and  insidiously  the  efforts  of  the 
physician.     C.  E.  de  M.  S.] 

Absorption  and  Elimination. — The 

absorption  of  alcohol  is  very  rapid, 
unless  it  be  so  concentrated  as  to  coagu- 
late the  albumins  with  v^hich  it  comes 
in  contact.  Roughly,  20  per  cent,  of 
alcohol  ingested  is  absorbed  from  the 
stomach,  and  the  remaining  80  per  cent, 
from  the  intestine.  Proceeding  to  the 
liver  with  the  portal  blood,  it  is  in  part 
arrested  in  this  organ,  the  other  portion 
passing  through  to  enter  the  general 
blood-stream.  Eventually  much  of  the 
latter  portion  leaves  the  capillaries  by 
exosmosis  and  is  absorbed  by  the 
various  tissues.  The  liver  and  brain 
have  a  special  affinity  for  alcohol,  the 


520 


ALCOHOL    (SAJOUS). 


former  fixing  four  times  and  the  latter 
twice  as  much  as  is  present  in  the  blood 
(Pouchet).  More  than  98  per  cent,  of 
.the  whole  amount  ingested  is  oxidized 
in  the  tissues  (Atwater).  The  re- 
mainder passes  out  with  the  urine  un- 
altered, though  traces  may  still  remain 
in  the  blood  after  the  first  twent}'-four 
hours.  The  aroma  of  the  breath  of 
alcohol  users  is  due  rather  to  higher 
alcohols  and  by-products  eliminated  in 
this  manner  than  to  ethyl  alcohol 
(Cushny).  According  to  Brauer,  some 
alcohol  is  excreted  with  the  bile,  then 
reabsorbed  from  the  intestinal  tract. 
An  insignificant  amount  may  leave  the 
body  with  the  sweat  and  milk.  The 
products  of  the  oxidation  of  alcohol  in 
the  system  are  believed  to  be  acetic  acid, 
carbon  dioxide,  and  water.  According 
to  the  researches  of  Dujardin-Beaumetz 
and  Jaillet,  it  is  oxidized  in  the  red  cells 
themselves,  with  the  formation  first  of 
acetates  of  the  alkali  metals,  then  of 
carbonates.  When  the  oxidizing  ca- 
pacity of  the  blood-cells  is  exhausted 
alcohol  begins  to  be  eliminated  in  large 
amount  with  the  emunctories  and  to 
accumulate  in  the  tissues. 

Role  of  Alcohol  in  Nutrition. — The 
painstaking  experiments  of  Neumann, 
of  Atwater  and  Benedict,  and  of  Rose- 
mann  have  shown  alcohol  to  be  capable 
of  sparing  the  fats  and  carbohydrates 
of  the  body  through  its  combustion  in 
their  stead,  i.e.,  where  the  amounts  of 
fat  and  carbohydrates  ingested  are  in- 
sufficient for  the  needs  of  the  body  alco- 
hol will,  to  a  certain  extent,  act  as  a 
substitute,  and  prevent  the  remaining 
reserve  of  these  substances  in  the  system 
from  being  exhausted.  The  combus- 
tion of  alcohol,  however,  yields  but  a 
comparatively  small  amount  of  heat, 
the  body  temperature  being,  therefore, 
seldom  raised  by  it,  but  rather  lowered, 


owing  to  the  peripheral  vasodilatation 
it  also  produces,  with  the  consequent  in- 
crease in  heat  loss.  Neumann  con- 
cluded from  his  experiments  that  alco- 
hol could  take  the  place  of  a  chemically 
equivalent  quantity  of  fat  in  the  diet, 
and  also  that  alcohol  given  in  combina- 
tion with  a  diet  in  itself  sufficient  would 
bring  about  an  economy  of  proteins — 
as  measured  by  the  nitrogen  excretion 
in  the  urine — in  the  same  way  that  an 
extra  amount  of  fat  would.  When 
moderate  amounts  of  alcohol  are  taken, 
the  first  result  is  an  increase  in  the 
amount  of  nitrogen  excreted,  which 
persists,  as  in  the  case  of  any  other 
change  in  the  non-nitrogenous  constit- 
uents of  the  food,  until  the  organism 
has  become  used  to  the  new  diet,  i.e., 
through  a  period  of  three  or  four  days. 
After  this  the  protein-saving  property 
of  alcohol  asserts  itself,  the  amount  of 
urea  and  uric  acid,  as  well  as  of  sul- 
phates and  phosphates,  eliminated  with 
the  urine  showing  a  decrease.  Accord- 
ing to  Pouchet,  however,  the  proteins 
are  spared  by  alcohol  only  if  the  subject 
is  receiving  in  the  diet  an  amount  of 
protein  in  excess  of  the  needs' of  the 
body  at  the  time.  If  not,  or  in  any 
case  if  the  administration  of  alcohol 
be  long  enough  cont^inued,  the  amount 
of  nitrogenous  wastes  will  soon  show 
an  increase  until  the  utilization  of  the 
body  proteins  becomes  greater  than 
normally — a  condition  of  affairs  un- 
favorable to  the  nutrition  of  the  body. 
The  same  result  will  obtain  at  once 
where  excessive,  instead  of  moderate, 
doses  of  alcohol  are  used,  the  drug 
acting  as  a  spur  to  the  breaking  down 
of  the  albumins. 

It  is  possible  to  prolong  the  life  of 
starving  rabbits  by  the  subcutaneous 
injection  of  suitable  doses  of  alcohol, 
but  larger  quantities  of  alcohol  hasten 


ALCOHOL    (SAJOUS). 


521 


the  death  of  the  animals.  The  favor- 
able action  of  the  alcohol  is  to  be 
ascribed  in  part  to  its  saving  effect 
on  albumin  and  the  better  preserva- 
tion of  the  watery  constituents  of  the 
organism.  The  acceleration  of  death 
under  the  influence  of  larger  quanti- 
ties is  to  be  explained  naturally  by 
the  increased  destruction  of  albumin. 
A  diuretic  action  is  produced  only  by 
the  administration  of  larger  quanti- 
ties of  alcohol,  smaller  quantities 
having-  an  opposite  effect.  Kochmann 
(Miinch.  med.  Woch.,  Mar.  16,  1909). 

The  advantages  of  alcohol  as  a  source 
of  body  energy  may  be  said  to  lie  in  its 
ready  absorption,  the  fact  that  no  diges- 
tion of  it  is  required,  and  that  it  is  easily 
oxidized.  In  fever  or  conditions  of 
central  nervous  exhaustion,  with  result- 
ing temporary  digestive  failure,  alcohol 
is,  therefore,  available  for  cautious  use 
as  a  food.  Roughly  speaking,  4  min- 
ims of  alcohol  will  yield  the  same 
amount  of  energy  as  7  grains  of 
sug-ar,  starch,  or  protein  or  3  grains 
of  fat  (Committee  of  Fifty,  1893). 

The  disadvantages  of  alcohol  are  that 
it  has  toxic  side  effects,  that  it  leads  to 
obesity,  and,  probably,  that,  even  in  the 
temperate,  it  tends  to  lower  the  resist- 
ing power  of  the  body  to  disease. 

M.  Duclaux  recently  declared,  on 
the  strength  of  a  number  of  experi- 
ments made  on  themselves  by  two 
American  investigators  (Atwater  and 

Benedict),  that  alcohol,  so  far  from 
being  a  poison,  has,  in  moderate 
doses,  a  distinct  dietetic  value.  This 
profession  of  faith,  made,  as  it  was, 
just  at  the  time  when  the  Academic 
de  Medecine  was,  at  the  request  of 
the  Minister  of  the  Interior,  drawing 
up  a  list  of  toxic  essences  employed 
in    the    manufacture    of    liquors,    and 

when  the  Prefect  of  the  Seine  had 
placarded    the    walls    of     Paris     with 

warnings  as  to  the  deadliness  of  alco- 
hol, caused  no  little  scandal  among 
the  antialcohol  party,  who,  with  the 
charity    characteristic    of    "antis"    of 


every  hue,  even  hinted  that  the  opin- 
ion of  the  distinguished  successor  of 
Pasteur  was  not  altogether  disinter- 
ested. This  ignoble  imputation  is 
mentioned  only  to  show  the  degree 
of  malevolence  and  mendacity  to 
which  the  minds  of  well-meaning  per- 
sons can  be  inflamed  by  prejudice.  In 
La  Revue,  M.  Duclaux  states  that  no 
definite  practical  consequences  can 
yet  be  drawn  from  the  experiments 
of  Atwater  and  Benedict.  He  is  anx- 
ious that  the  question  should  be  fully 
discussed,  but  he  awaits  the  coming 
of  adversaries  who  will  consent  to 
read  and  reflect  before  rushing  into 
print.  In  the  mean  time  he  will  agree 
to  a  truce,  accepting  as  an  average 
one  liter  of  wine  a  day,  an  amount 
which  has  been  shown  by  the  Ameri- 
can investigators  to  be  harmless  and 
even  useful.  The  wine  must  be  well 
diluted  with  water,  and  its  consump- 
tion spread  over  a  day. 

Roux,  also  of  the  Pasteur  Institute, 
holds  that,  even  if  Atwater  and  Bene- 
dict's experiments  be  accepted,  the 
fight  against  alcohol  must  still  be  con- 
tinued. He  thinks  that  habitual  drinkers 
will  never  submit  to  the  restricted  allow- 
ance which  Atwater  and  Benedict  im- 
posed on  themselves.  In  regard  to 
wine,  Roux  admits  that  the  experi- 
ence of  centuries  as  seen  in  whole 
nations  shows  that  moderate  drinking 
does  no  harm.  Metchnikoff  holds  that 
alcohol  in  any  form  is  a  poison.  He 
confesses,  however,  that  he  has  not 
made  a  special  study  of  the  question, 
and  his  conclusion  is  based  on  his 
personal  experience.  He  never  drinks 
alcohol  himself,  as  he  has  found  that 
even  a  small  quantity  makes  him 
giddy.  Berthelot  is  clear  that  alcohol 
is  not  a  food.  In  very  small  doses  it 
may  be  useful  as  a  medicine.  He 
thinks  alcoholism  is  a  factor  in  the 
present  decadence  of  most  European 
nations,  and  that  their  only  hope  of 
salvation  lies  in  vigorous  legislation 
against  the  evil.  Brouardel  gives  the 
guarded  reply  that  from  the  chemical 
constitution  of  a  body  no  conclusion 
can  be  drawn  as  to  its  alimentary 
value;    experience   alone    can   decide 


522 


ALCOHOL    (SAJOUS). 


the  question.  Charles  Richet  says 
there  is  no  doubt  that  alcohol  is  a 
food,  and  that  in  very  small  doses, 
when  pure,  it  is  almost  harmless. 
This  fact,  however,  does  not  warrant 
the  inference  that  it  is  a  good  food. 
He  thinks  that  men  must  be  angels 
before  alcohol  ceases  to  be  a  great 
danger.  It  is  a  mischievous  delusion 
to  think  that  alcohol  is  consumed  as 
a  food;  it  is  rather  its  poisonous  ef- 
fects that  are  sought  by  unfortunates 
anxious  to  forget  their  misery.  Pro- 
fessor Bernheim,  of  Nancy,  does  not 
think  that  the  use  of  alcohol  should 
be  proscribed.  He  even  holds  that 
many  abstainers  from  "the  generous 
wine  of  France"  are  actuated  by 
snobisme.  Wine,  he  says,  is,  like  other 
medicines,  poisonous  only  in  large 
doses.  It  would  be  as  reasonable  to 
forbid  its  use  on  that  account  as  to 
condemn  the  eating  of  meat  because 
it  contains  ptomaines,  or  eggs  because 
phosphorus  enters  into  their  compo- 
sition. Like  everything  that  we  take, 
wine  suits  some  and  not  others. 

Lancereaux  also  holds  that  wine  is 
dangerous  only  if  taken  in  too  great 
quantity — for  instance,  in  a  daily 
quantity  of  3  liters.  Alcohol  in  every 
form,  however,  if  taken  to  excess, 
brings  on  premature  senility  and  tends 
directly  to  tuberculosis  and  death. 
Hericourt  holds  that,  to  the  question,  Is 
alcohol  food?  no  absolute  answer  can 
be  given.  Every  food  is  toxic  in  cer- 
tain amounts,  and,  although  the  con- 
sumption of  a  liter  of  wine  a  day  may 
have  been  a  direct  cause  of  the  death  of 
anyone,  it  may  be  so  indirectly,  as  by 
diminishing  the  power  of  resistance  to 
disease. 

Dr.  Landouzy  is  of  the  opinion  that 
natural  wine  taken  in  doses  suitable 
to  age,  constitution,  and  mode  of  life 
does  not  deserve  the  uncompromising 
condemnation  of  intemperate  advo- 
cates of  temperance;  he  looks  upon 
spirits  and  liqueurs,  however,  as,  gen- 
erally speaking,  pernicious.  Magnan 
thinks  that,  whatever  chemistry  or  ex- 
perimental physiology  may  appear  to 
show,  alcohol  can  never  be  recom- 
mended  as   a  food.     Garnier,  speak- 


ing from  a  large  prison  experience, 
says  that  alcohol  is  responsible  for 
70  per  cent,  of  all  the  crimes  com- 
mitted in  France.  Bourneville  is  not 
hostile  to  wine;  he  holds,  with  Du- 
claux,  that,  from  the  hygienic  point 
of  view,  it  is  distinctly  useful  in  mod- 
erate doses. 

On  the  whole,  then,  the  weight  of 
opinion  among  leading  scientific  men 
in  France  is  in  favor  of  the  dietetic 
value  of  wine.  But  the  wine  must  be 
pure  and  it  must  be  taken  in  moderate 
amount.  Those  who,  like  Cassio  and 
Metchnikoff,  have  very  poor  and  un- 
happy brains  for  drinking  ought,  by 
all  means,  to  avoid  looking  upon  the 
wine  when  it  is  red.  They  have  no 
right,  however,  to  make  this  personal 
idiosyncrasy  the  measure  of  other 
people's  tolerance,  still  less  to  found 
upon  it  a  universal  law  for  the  gov- 
ernance of  mankind. 

As  to  the  deadly  effects  of  the  abuse 
of  alcohol  we  are  all  agreed,  and  prob- 
ably all  will  also  agree  that  its  use 
should  be  carefully  regulated  in  ac- 
cordance with  individual  constitution. 
The  experience  of  men  differs.  Glad- 
stone, who  had  an  "open  mind"  in 
most  directions,  tested  the  matter  for 
himself.  He  found  that  wine  helped 
him  when  he  had  to  make  an  ex- 
traordinary oratorical  effort,  and  the 
want  of  it  made  the  effort  more  labori- 
ous and  less  successful.  On  the  other 
hand,  some  find  that  wine  paralyzes 
their  faculties.  In  regard  to  alcohol, 
it  may  be  said  with  truth  that  what 
is  one  man's  meat  is  another  man's 
poison,  and  that  homely  proverb 
seems  to  us  to  sum  up  the  teachings 
of  science  and  philosophy  on  the  ques- 
tion. Editorial  (Brit.  Med.  Jour., 
Mar.  14,  1903). 

The  following  comparative  table 
represents  demonstrable  facts  and  the 
teachings  of  laboratory  work  :^ 

Food.  Alcohol. 

1.  A  certain  quan-  1.  A  certain  quan- 
tity will  produce  a  tity  will  produce  a 
certain  effect  at  first;  certain  effect  at  first, 
the  same  quantity  but  it  requires  more 
will  always  produce  and  more  to  produce 
the  same  effect  in  the  same  effect  when 
the  healthy  body.  the  drug  is  used 
habitually. 


ALCOHOL    (SAJOUS). 


523 


Food  {Oontinued). 

2.  The  habitual 
use  of  food  never  in- 
duces an  uncontrol- 
lable desire  for  it 
in  ever-increasing- 
amounts. 

3.  After  its  habit- 
ual use  a  sudden  to- 
tal abstinence  never 
causes  any  derange- 
ments of  the  central 
nervous  system. 

4.  Foods  are  oxi- 
dized slowly  in  the 
body. 

5.  Foods,  being 
useful,  are  stored  in 
the   body. 

6.  Foods  are  the 
products  of  con- 
structive activity, 
activity  of  proto- 
plasm in  the  pres- 
ence of  abundant 
oxygen. 

7.  Foods  (except 
meats)  are  formed  in 
nature  for  the  nour- 
ishment of  living  or- 
ganisms, and  are, 
therefore,  inherently 
wholesome. 

8.  The  regular  in- 
gestion of  food  is 
beneficial  to  the 
healthy  body,  but 
may  be  deleterious 
to   the  sick. 

9.  The  use  of  foods 
is  followed  by  no  re- 
action. 


10.  The  use  of  food 
is  followed  by  an  in- 
crease in  activity  of 
the  muscle-cells  and 
brain-cells. 

11.  The  use  of  food 
is  followed  by  an  in- 
crease in  the  excre- 
tion of  carbonic 
oxide. 

12.  The  use  of  food 
may  be  followed  by 
accumulation  of  fat, 
notwithstanding  in- 
creased activity. 

13.  The  use  of  food 
is  followed  by  a  rise 
in  body  temperature. 

14.  The  use  of  food 
strengthens  and 
Steadies  the  muscles. 


Alcohol  {Continued}. 

2.  When  used  ha- 
bitually it  is  likely 
to  induce  an  uncon- 
trollable desire  for 
more,  in  ever-in- 
creasing   amounts. 

3.  After  its  habit- 
ual use  a  sudden  to- 
tal abstinence  is 
likely  to  cause  a  se- 
rious derangement  of 
the  central  nervous 
system. 

4.  Alcohol  is  oxi- 
dized rapidly  in  the 
body. 

5.  Alcohol,  not  be- 
ing useful,  is  not 
stored    in    the    body. 

6.  Alcohol  is  a 
product  of  decompo- 
sition of  food  in  the 
presence  of  abundant 
oxygen. 


7.  Alcohol  is  formed 
in  nature  only  as 
an  excretion.  It  is, 
therefore,  in  common 
with  all  excretions, 
inherently  poisonous. 

8.  The  regular  in- 
gestion of  alcohol  is 
deleterious  to  the 
healthy  body,  but 
may  be  beneficial  '■o 
the  sick  (through  its 
drug  action). 

9.  The  use  of  al- 
cohol, in  common 
with  narcotics  in 
general,  is  followed 
by    a    reaction. 

10.  The  use  of  al- 
cohol is  followed  by 
a  decrease  in  the  ac- 
tivity of  the  muscle- 
cells  and  brain-cells. 

11.  The  use  of  al- 
cohol is  followed  by 
a  decrease  in  the  ex- 
cretion of  carbonic 
oxide. 

12.  The  use  of  al- 
cohol is  usually  fol- 
lowed by  an  accumu- 
lation of  fat  through 
decreased    activity. 

13.  The  use  of  al- 
cohol may  .  be  fol- 
lowed by  a  fall  in 
body  temperature. 

14.  The  use  of  al- 
cohol weakens  and 
unsteadies  the  mus- 
cles. 


Food  (Concluded). 

15.  The  use  of  food 
makes  the  brain 
more  active  and  ac- 
curate. 


Alcohol  {Concluded). 
15.  The    use    of    al- 
cohol       makes        the 
brain  less  active  and 
accurate. 


[Alcohol  is  considered  as  a  food-sparing 
agent  by  some  observers,  its  value  corre- 
sponding with  its  dynamic  equivalent  of 
pure  food  hydrocarbon.  This  presupposes, 
however,  that  alcohol  is  utilized  by  the 
tissues  in  the  same  manner  as  these  hy- 
drocarbons— merely  because  its  oxidation 
liberates  energy  in  the  form  of  heat.  But 
this  is  a  fallacious  conception;  alcohol 
only  simulates  normal  oxidations;  far 
from  being  the  product  of  cellular  ex- 
changes which  constitute  the  vital  process, 
the  heat  it  liberates  is  at  the  expense  of 
the  tissue,  since  by  becoming  oxidized 
itself,  especially  in  the  liver — whereby  the 
body  is  protected  against  its  toxic  effects 
— it  utilizes  oxygen  intended  to  sustain 
tissue  metabolism.  If  alcohol  were  a  food, 
large  doses  would  prove  more  profitable 
to  the  organism  than  small  ones;  but  the 
reverse  is  the  case;  large  doses  inhibit  all 
activities  tha,t  would  be  enhanced  by  a  ^ 
liberal  use  of  food.  The  debilitating 
action  of  alcohol  on  the  nervous  system, 
for  example,  has  been  demonstrated  by 
Bunge,  Schmiedeberg,  Ach  and  Krepelin, 
and  others,  while  Dogiel  found  that  it  de- 
pressed markedly  both  motor  and  sensory 
nerve-centers.  It  does  this  not  only  with 
nervous  tissue,  but  with  all  tissues.  A 
depressing  agent  cannot  logically  be  re- 
garded as  a  food.     C.  E.  de  M.  S.] 

In  healthy  persons  alcohol  unques- 
tionably plays  the  same  role  as  a  food, 
e.g.,  a  carbohydrate  or  a  fat.  In  con- 
trast to  fats  and  carbohydrates,  alco- 
hol spares  the  proteids  only  in  those 
cases  in  which  the  organism  has  be- 
come accustomed  to  the  action  of  the 
stimulant,  which  usually  takes  sev- 
eral days.  In  disease  alcohol  appar- 
ently acts  upon  metabolism  in  the 
same  way  as  in  health.  It  is  particu- 
larly useful  as  a  food  in  diabetes  mel- 
litus;  by  taking  the  place  of  fats  in 
the  food  it  lessens  the  production  of 
the  acetone  bodies.  Hare  showed 
that  alcohol  raises  the  power  of  the 
blood  to  destroy  bacteria.  Fried- 
berger  found  that  under  the  influence 


524 


ALCOHOL   (SAJOUS). 


of  alcohol  the  blood  acquired  an  in- 
creased resistance  against  the  cholera 
vibrio.     Mircoli  found  that  under  the 
influence  of  alcohol  the  body  acquired 
the  power  to  resist  the  tubercle  bacil- 
lus.    A.  K.  Sievert  (Roussky  Vratch, 
Oct.  24,  1909;  N.  Y.  Med.  Jour.,  Jan.  1, 
1910). 
[The  protective  influence  of  alcohol  re- 
ferred to  here  applies   to   small   quantities 
only.     Everyone   knows   and   hospital    ex- 
perience has  amply  and  conclusively  shown 
that  alcoholism  greatly  weakens  the  power 
of   the   body   to   resist   disease.      C.   E.   de 
M.  S.] 

External  Action. — Applied  to  the 
skin  and  allowed  to  evaporate,  alcohol 
reduces  the  local  temperature  because 
of  its  marked  volatility.  It  may  also 
exert  an  anesthetic  effect.  If  evapora- 
tion be  prevented,  however,  and  the 
contact  maintained  for  some  time,  alco- 
hol acts  as  an  irritant.  Owing  to  its 
rather  high  diffusion  power,  it  pene- 
trates through  the  cuticle  to  the  un- 
derlying tissues,  and  induces  a  sen- 
sation of  heat,  often  preceded  by 
itching  and  accompanied  by  red- 
dening of  the  skin  surface.  It  may 
thus  be  employed  as  a  counter- 
irritant.  For  such  effects  a  concentra- 
tion of  about  60  per  cent,  or  over  is  re- 
quired, more  dilute  solutions  not  giving 
rise  to  distinctly  irritative  phenomena. 
When  applied  to  ulcers  and  other  open 
surfaces,  alcohol  may,  through  its  irri- 
tant properties,  hasten  tissue  repair. 
The  prominent  local  effects  of  concen- 
trated alcohol  include  the  abstraction  of 
water  from  the  tissues,  and  the  coagula- 
tion of  albumin.  It  is  because  of  these 
effects,  and  also  by  dissolving  out  the 
fat,  that  alcohol  hardens  the  skin  when 
repeatedly  applied.  It  is  sometimes 
used  to  cover  sores  or  wounds  with  a 
thin,  protective,  air-excluding  layer  of 
coagulated  albumin,  which  facilitates 
healing.     Alcohol  may  also  act  as  an 


astringent,  a  property  not  infrequently 
availed  of  in  such  condition  as  saliva- 
tion, pharyngeal  relaxation,  scurvy,  etc., 
alcoholic  preparations  being  employed 
as  mouth-washes  and  gargles.  The  irri- 
tant and  astringent  powers  of  alcohol 
are  naturally  more  pronounced  upon  the 
mucous  membranes  and  upon  wound 
surfaces  than  upon  the  skin,  and  dilute 
preparations  can,  therefore,  be  used  on 
the  former  to  procure  effects  such  as 
only  concentrated  ones  would  produce 
on  the  skin.  Inhalation  of  the  vapors 
of  alcohol  is  capable  of  causing  tempo- 
rary spasm  of  the  laryngeal  muscles 
through  reflex  irritation.  Alcohol  has 
noteworthy  antiseptic  and  germicidal 
properties,  which  may  be  utilized  in  the 
disinfection  of  wounds.  According  to 
Harrington  and  Walker,  60  and  70  per 
cent,  alcoholic  solutions,  applied  to 
wounded  surfaces  for  at  least  five, 
minutes,  are  the  most  efficient  in  de- 
stroying bacteria.  In  these  percentages 
alcohol  corresponds  in  strength  to  about 
3  per  cent,  phenol  (Cushny).  Dry 
bacteria  may  not  be  destroyed  by  a  day's 
exposure  to  absolute  alcohol. 

Against  dry  bacteria,  absolute  alco- 
hol and  ordinary  commercial  alcohol 
are  wholly  devoid  of  bactericidal 
power,  even  with  twenty-four  hours' 
direct  contact,  and  other  preparations 
of  alcohol  containing  more  than  70 
per  cent.,  by  volume,  are  weak  in  this 
regard,  according  to  their  content  of 
alcohol, — the  stronger  in  alcohol,  the 
weaker  in  action.  Against  the  com- 
moner, non-sporing,  pathogenic  bac- 
teria in  a  moist  condition,  any  strength 
of  alcohol  above  40  per  cent.,  by  vol- 
ume, is  effective  within  five  minutes, 
and  certain  preparations  within  one 
minute.  Alcohol  of  less  than  40  per 
cent,  strength  is  too  slow  in  action 
or  too  uncertain  in  results  against 
pathogenic  bacteria,  whether  moist 
or  dry.  The  most  effective  dilutions 
of  alcohol  against  the  strongly  resist- 


ALCOHOL    (SAJOUS). 


525 


ant  (non-sporing)  bacteria,  such  as 
the  pus  organisms,  in  the  dry  state, 
are  those  containing  from  60  to  70 
per  cent.,  by  volume,  which  strengths 
are  equally  efficient  against  the  same 
organisms  in  a  moist  condition.  Un- 
less the  bacterial  envelope  contains  a 
certain  amount  of  moisture,  it  is  im- 
pervious to  strong  alcohol;  but  dried 
•  bacteria,  when  brought  into  contact 
with  diluted  alcohol  containing  from 
30  to  60  per  cent,  of  water  by  volume, 
will  absorb  the  necessary  amount  of 
water  therefrom  very  quickly,  and 
then  the  alcohol  itself  can  reach  the 
cell  protoplasm  and  destroy  it.  The 
stronger  preparations  of  alcohol  pos- 
sess no  advantage  over  60  to  70  per 
cent,  preparations,  even  when  the  bac- 
teria are  moist;  therefore,  and  since 
they  are  inert  against  dry  bacteria, 
they  should  not  be  employed  at  all 
as  a  means  of  securing  an  aseptic  con- 
dition of  the  skin.  Provided  the  skin 
bacteria  in  the  deeper  parts  can  be 
brought  into  contact  with  disinfect- 
ants, alcohol  of  from  60  to  70  per 
cent,  strength  may  be  depended  upon 
usually,  but  not  always,  to  destroy 
them  within  five  minutes.  Charles 
Harrington  and  Harold  Walker  (Bos- 
ton Med.  and  Surg.  Jour.,  May  21, 
1903). 

THERAPEUTICS.— As  a  "Stim- 
ulant."— The  opinion  of  the  medical 
profession  in  regard  to  the  value  of 
alcohol  as  a  stimulant  is  divided,  and 
the  extent  to  which  the  drug  is  em- 
ployed in  the  treatment  of  disease  (ex- 
ception being  made  of  its  external  uses) 
is  on  the  decline. 

The  more  recent  studies  have  brought 
out  the  importance  of  the  vasodilator 
influence  of  alcohol,  and  cast  a  shadow 
on  its  effectiveness  as  a  true  stimulant. 
By  many  it  is  believed  that  a  part,  if 
not  all,  of  the  stimulating  effect  of 
alcohol  results  from  the  local  irritation 
produced  by  it  in  the  stomach,  the 
centers  in  the  medulla  oblongata  being 
thereby  excited  reflexly. 


[Buchner,  Chittenden,  Mendel,  Jackson, 
and  many  other  authorities  have  shown 
that  beverages  which  contain  a  small  pro- 
portion, about  5  per  cent.,  of  absolute 
alcohol,  such  as  light  wines,  beer,  etc., 
increased  the  production  of  gastric  juice 
and  the  activity  of  the  digestive  process. 
Being  entirely  oxidized  in  the  stomach  and 
promptly  eliminated  by  the  lungs  and  kid- 
neys, this  small  percentage,  unless  taken 
in  large  quantities,  does  not  influence 
morbidly  either  the  blood  or  its  oxidizing 
body.  Such  is  not  the  case,  however,  when 
the  proportion  of  absolute  alcohol  exceeds 
5  per  cent,  to  any  marked  degree.  A 
beverage  containing  10  per  cent.,  for  ex- 
ample, retards  digestion  manifestly,  and  if 
stronger,  as  is  the  case  with  brandy, 
Avhisky,  etc.,  it  tends  besides,  as  first 
shown  by  Claude  Bernard,  to  cause  coagu- 
lation of  the  gastric  secretion  and  its  fer- 
ments. Under  these  conditions,  the  func- 
tions of  the  digestive  tract  are  not  alone 
interfered  with,  but  considerable  alcohol 
is  absorbed  into  the  blood.  It  is  this 
absorbed  alcohol  which  does  incalculable 
harm.  Being  oxidized  at  the  expense  of 
the  blood's  oxidizing  body — of  adrenal 
origin — it  robs  the  tissues  of  that  which 
sustains  their  life.     C.  E.  de  M.  S.] 

Partly  because  of  the  fact  that  it  is 
often  the  only  remedial  agent  imme- 
diately available,  it  is  still  largely  admin- 
istered, especially  by  the  laity,  in  all 
varieties  of  emergencies.  Its  effect, 
though  of  short  duration,  is  exerted 
promptly. 

As  a  cardiac  and  respiratory  stimu- 
lant alcohol  is  made  use  of  in  imme- 
diately dangerous  conditions,  such  as 
syncope,  shock,  collapse,  severe  hem- 
orrhage, asphyxia,  and  poisoning  by 
depressant  drugs,  as  well  as,  in  many 
instances,  in  the  course  of  acute  in- 
fectious diseases,  such  as  typhoid 
fever,  typhus,  pneumonia,  diphtheria, 
small-pox,  scarlatina,  septicemia,  ery- 
sipelas, tetanus,  yellow  fever,  cholera, 
dysentery,  influenza,  etc.  The  con- 
sensus of  present  opinion  is  that 
alcohol  should  never  be  administered 


526 


ALCOHOL    (SAJOUS). 


continuously,  even  in  severe  infec- 
tions, but  should  be  reserved  for 
periods  of  unusual  depression,  when 
special  stimulation  is  necessary  to  tide 
the  patient  over  a  dangerous  crisis.  In 
selecting  the  dose  to  be  used,  the  vaso- 
dilator influence  of  alcohol  must  always 
be  remembered,  excessive  doses  tending 
to  lower  markedly  the  tone  of  the  blood- 
vessels,— the  importance  of  which  tone 
in  the  maintenance  of  cardiac  activity  is 
well  recognized.  According  to  many, 
indeed,  the  use  of  alcohol  in  shock  is  to 
be  avoided,  as  this  is  a  condition  of 
paretic  vasodilation,  and  the  vaso- 
dilator effect  of  alcohol  exerted  after 
its  absorption  is  likely  to  prove  more 
harmful  than  its  primary  reflex  stimu- 
lating effect  on  the  heart  and  respiration 
will  have  done  good.  Similarly  in 
severe  hemorrhage,  alcohol  has  been 
said  to  be  contraindicated,  owing  to  its 
vasodilator  property. 

While  alcohol  may  stimulate  the 
heart  and  raise  arterial  pressure  mo- 
mentarily, its  secondary  effect  is  that 
of  a  cardiac  depressant  and  a  vaso- 
dilator. The  only  time  when  alcohol 
is  a  stimulant  is  in  acute  cardiac  fail- 
ure, and  then  it  is  stimulant  to  the 
heart  only  before  its  absorption,  re- 
flexly  from  the  irritation,  when  taken 
in  concentrated  solution,  of  the  mu- 
cous membrane  of  the  mouth,  phar- 
ynx, esophagus,  and  stomach,  the  rec- 
tum, if  it  is  administered  as  an  enema, 
and  the  tissues,  if  it  is  given  hypo- 
dermically.  To  obtain  such  stimula- 
tion the  alcohol  must  be  in  strong 
preparation — either  brandy,  whisky, 
gin,  rum,  or  champagne.  This  reflex 
irritation  through  the  vasomotor  cen- 
ter temporarily  raises  the  blood- 
pressure,  and  perhaps,  through  the 
accelerator  nei'ves,  stimulates  the 
heart.  To  keep  up  this  stimulation 
another  dose  must  soon  be  given,  in 
from  fifteen  minutes  to  half  an  hour 
or  an  hour,  depending  on  the  pro- 
longation of  the  heart  weakness.    The 


dose  of  alcohol  for  such  stimulation 
should  be  small  in  order  that  the  re- 
sults from  the  subsequent  absorption 
will  be  the  minimum,  as  the  vaso- 
dilator effects  are  not  desired.  If  the 
alcohol  is  administered  too  frequently 
it  accumulates  in  the  system  before 
the  previous  doses  can  be  burned  or 
eliminated,  and  then  to  obtain  stimu- 
lation it  will  be  necessary  to  give  a 
larger,  concentrated  dose  to  cause 
sufficient  irritation  and  stimulation  to 
overcome  the  depression  of  the  pre- 
vious doses.  Soon  the  vasodilation 
is  increased,  the  heart  is  depressed. 
the  nervous  system  more  or  less  par- 
alyzed, and  depression  is  added  to 
depression.  Consequently,  the  only 
excuse  for  using  alcohol  in  any  form 
as  a  cardiac  or  circulatory  stimulant 
is  when  the  depression  or  syncope  is 
short-lived,  or,  perhaps,  as  a  primary 
stimulant  in  acute  collapse.  (Jour. 
Amer.  Med.  Assoc,  Nov.  6,  1909.) 

Observations  on  the  remarkable 
stimulant  effect  on  the  heart  and  cir- 
culatory system  produced  by  the  in- 
halation of  oxygen  containing  alcohol 
vapor.  There  are  the  good  effects  of 
the  oxygen  plus  an  additional  marked 
stimulant  effect  on  the  circulation 
caused  by  the  contained  alcohol  va- 
por. Oxygen  which  had  been  bub- 
bled through  absolute  alcohol  con- 
tained in  an  ordinary  wash-bottle  was 
administered  in  several  cases  of  ill- 
ness in  which  cardiac  failure  was  a 
prominent  symptom,  and  it  was  found 
that  the  mixture  produced  a  marked 
stimulant  effect  on  the  heart  and  cir- 
culation, decidedly  greater  than  that 
produced  by  oxygen  alone.  In  some 
of  these  cases  the  administration  ap- 
peared to  have  been  the  cause  of  pro- 
longation and  saving  of  life.  In  cases 
of  pneumonia  with  cardiac  failure 
the  mixture  of  oxygen  and  alcohol 
vapor  was  found  to  be  a  valuable 
remedy.  Willcox  and  Collingwood 
(Brit.  Med.  Jour.,  Nov.  5,  1910). 

In  emergency  conditions,  large  doses 
of  alcohol,  e.g.,  1  or  2  ounces  (30  to  60 
c.c.)  of  whisky  or  brandy,  are  not  in- 
frequently administered.    Where,  owing 


ALCOHOL    (SAJOUS). 


527 


to  unconsciousness  or  profound  adyna- 
mia, the  spirits  cannot  be  swallowed, 
they  may  be  injected  subcutaneously. 
By  this  method  absorption  of  the  drug 
is  more  rapid,  and  its  general  effect  cor- 
respondingly hastened.  Alcohol  may 
also  be  given  by  rectum,  preferably  in 
the  form  of  brandy. 

In  the  treatment  of  wounds  inflicted 
by  venomous  snakes  and  poisonous 
fishes,  the  internal  use  of  alcohol  has 
long  been  considered  an  effective 
measure,  though  the  idea  that  the  drug 
exerts  a  specific  antidotal  effect  in 
these  cases  appears  to  be  based  on  pure 
assumption.  Large  doses  are  customa- 
rily given  in  these  cases,  but  this  should 
certainly  not  be  pushed  to  the  point  of 
adding  an  acute  alcoholic  intoxication  to 
the  difficulties  with  which  the  system 
already  has  to  contend. 

In  the  prostration  attending  cases  of 
meat  poisoning  or  ergotism,  the  ad- 
miinistration  of  alcohol  also  often 
proves  valuable. 

As  a  Vasodilator. — The  value  of 
alcohol  in  feverish  or  frankly  febrile 
conditions  depends  in  reality  on  not  a 
single,  but  a  group,  of  effects,  which 
have  been  enumerated  by  Sollmann  as 
follows:  1.  Dilatation  of  the  cutaneous 
vessels.  2.  Counteraction  of  the  nerv- 
ous phenomena  of  fever,  through  nar- 
cotic action.  3.  The  furnishing  of  a 
readily  absorbable  food.  4.  Diuresis. 
Among  these  effects  peripheral  vaso- 
dilation ranks  as  the  most  important. 
AVhen  the  pulse  becomes  of  the  high- 
tension  variety,  owing  to  excitation  of 
the  contractile  vascular  walls  by  dis- 
ease toxins,  and  the  superficial  circula- 
tion becomes  sluggish,  for  the  same 
reason,  alcohol  is  likely  to  prove  bene- 
ficial by  dilating  the  vessels,  lowering 
the  tension,  facilitating  the  work  of  the 
heart,  and  prornpting  perspiration.     It 


will  act  thus  pre-eminently  as  a  restorer 
of  the  circulatory  ecjuilibrium.  Certain 
particular  indications  for  the  use  of 
alcohol  in  fevers  have  been  formulated, 
viz.,  where  in  addition  to  a  frequent, 
small,  or  irregular  pulse  or  respiratory 
depression  there  are  present  dryness  of 
the  tongue  and  skin,  together  with  rest- 
lessness and  delirium  or,  on  the  other 
hand,  indifference  and  hebetude,  and 
perhaps  subsultus  tendinum, — phenom- 
ena commonly  grouped  under  the  term 
"typhoid  state."  While,  in  a  general 
way,  the  validity  of  these  indications 
for  alcohol  seems  to  be  established  upon 
the  basis  of  past  experience,  it  cannot 
be  said  that  the  drug  will  invariably  be 
productive  of  benefit  where  the  indica- 
tions are  present.  If,  alcohol  having 
been  administered,  the  pulse  and  res- 
piration are  improved,  the  mouth  and 
skin  rendered  moist,  and  the  mental 
condition  corrected,  the  propriety  of 
employing  it  in  the  individual  case  will 
become  apparent. 

As  a  vasodilator  in  chronic  high  arte- 
rial tension  alcohol  should  ordinarily 
not  be  used.  This  indication  is  present 
in  arteriosclerosis  and  gout,  and  is  a 
symptom  and  sign  in  late  middle  life 
or  old  age.  If  the  condition  requires 
treatment  it  is  much  better  managed  by 
nitroglycerin,  thyroid  extract,  potassium 
iodide,  or  small  doses  of  chloral.  If 
arteriosclerosis  is  present  and  the  pa- 
tient is  well  along  in  life  and  is  accus- 
tomed and  has  been  accustomed  to  take 
alcohol  regularly  in  doses  that  do  not 
intoxicate,  it  may  be  unwise  to  stop  the 
vasodilating  effects  of  the  alcohol  until 
it  has  been  ascertained  that  some  other 
treatment  will  be  as  conducive  to  his 
well-being.  In  other  words,  the  physio- 
logical relief  from  high  tension  which  he 
has  been  accustomed  to  acquire  by  tak- 
ing alcohol  cannot  be  abruptly  stopped 
without  due  consideration  of  the  con- 
sequences of  withdrawing  the  drug. 
(Jour.  Amer.  Med.  Assoc,  Nov.  6, 
1909.) 


528 


ALCOHOL    (SAJOUS). 


The  dose  of  alcohol  given  in  the  feb- 
rile diseases  has  usually  been  that  rep- 
resented by  ^  to  1  ounce  (15  to  30  c.c.) 
of  whisky  or  brandy,  diluted  with  water, 
this  amount  being  repeated  every  two 
to  four  hours.  AMiile  it  has  been  a  mat- 
ter of  common  observation  that  very 
large  doses  of  alcohol  may  be  given  in 
fever  without  eliciting  the  ordinary 
signs  of  intoxication,  this  fact  should 
not  be  interpreted  as  giving  the  physi- 
cian license  to  introduce  alcohol  into 
the  systems  of  patients  without  due 
consideration  of  the  dosage.  It  should 
be  kept  in  mind  that  alcohol,  though  set- 
ting free  energy  in  the  form  of  heat 
through  its  oxidation,  in  doing  so  draws 
upon  the  supply  of  oxygen  present  in 
the  tissues,  and  if  caused  to  accumulate 
in  the  system  through  injudicious 
dosage  is  hkely  seriously  to  interfere 
with  other  oxidative  processes  essential 
to  the  welfare  of  the  economy.  Hence 
the  tendency  recently  has  been,  if  alco- 
hol is  used  at  all  in  fever,  to  limit 
strictly  the  amount  given  to  what  is 
necessary  for  amelioration  of  the 
symptoms. 

According  to  Osborne,  a  dose  larger 
than  1  to  3  teaspoonfuls,  once  every 
three  hours,  is  probably  never  indicated 
in  febrile  conditions ;  if  this  dosage  be 
exceeded,  the  harmful  effects  resulting 
when  alcohol  is  given  in  amounts  that 
overtax  the  oxidizing  powers  of  the 
tissues  and  lead  to  accumulation  of  the 
drug  in  the  system  will  be  avoided. 
Butler  counsels  that,  even  in  cases 
where  alcohol  proves  beneficial,  it 
should  rarely  be  given  throughout  the 
twenty-four  hours,  but  reserved  for 
periods  when  the  heart  action  grows 
especially  weak,  usually  in  the  interval 
between  midnight  and  7a.m.  One  fluid- 
ounce  (30  c.c.)  of  whisky  may  be  given 
before    midnight    and    repeated    every 


three  hours.  In  lieu  of  pure  whisky  or 
brandy,  diluted  alcohol  may  also  be  ad- 
vantageously given  in  the  form  of  milk 
punch  or  eggnog. 

In  infectious  diseases  alcohol  should 
never  be  given  unless  the  patient  is 
near  collapse.  Even  in  small  doses  it 
weakens  the  resistance,  and  so  favors 
the  action  of  the  invading  microbe. 
It  is  a  cause  of  stillborn  infants,  with 
more  or  less  widespread  fatty  degen- 
eration. Gruber  (Wiener  klin.Woch., 
May  9,  1901). 

The  effect  of  alcohol  on  the  circula- 
tion in  the  sick,  and  its  effect  on  the 
power  of  man's  blood  to  resist  infec- 
tion, studied  experimentally.  Only 
the  results  of  study  of  the  first  of 
these  two  problems  are  now  reported. 
The  following  facts,  regarding  the 
action  of  alcohol,  the  author  considers 
as  already  established  by  the  investi- 
gations of  many  observers :  (a)  In 
health  alcohol  can  replace  the  fats 
and  carbohydrates.  Whether  it  can 
replace  the  proteids  is  not  yet  set- 
tled. Alcohol  is  both  a  food  and  a 
poison.  (&)  In  the  stomach  alcohol 
disturbs  the  digestive  process  to  a 
greater  or  less  degree.  After  absorp- 
tion it  exerts  through  the  nervous 
system  a  temporary  increase  both  in 
the  secretion  and  in  the  motility  of 
the  stomach.  On  intestinal  absorp- 
tion, so  far  as  known,  alcohol  exerts 
little  or  no  influence,  (c)  In  healthy 
people  and  in  persons  with  cardiac 
and  renal  diseases  alcohol  has  no  con- 
siderable diuretic  power.  In  healthy 
people  it  rather  decreases  than  in- 
creases diaphoresis,  (d)  The  labor  of 
respiration  is  increased  by  alcohol, 
yet  there  is  no  increase  in  the  amount 
of  O  absorbed,  nor  in  the  quantity  of 
CO9  given  off.  To  the  above  facts 
regarding  the  action  of  alcohol  the 
writer  adds  the  following,  ascertained 
experimentally:  1.  The  action  of  alco- 
hol upon  the  circulation  is  nil.  Neither 
the  maximum  nor  minimum  blood- 
pressure  showed  any  variation  that 
could  reasonably  be  attributed  to  the 
action  of  alcohol.  2.  From  the  study 
of  309  patients  suffering  from  a  great 


ALCOHOL    (SAJOUS). 


529 


variety  of  diseases  it  would  seem  that 
alcohol,  in  therapeutic  doses,  has  no 
effect  on  the  temperature,  pulse  rate, 
respiration  rate,  appetite,  delirium,  and 
secretions.  These  observations  should 
not,  however,  be  interpreted  as  prov- 
ing that  alcohol  is  useless  or  useful  in 
disease.  R.  C.  Cabot  (Boston  Med. 
and  Surg.  Jour.,  July  23,  1903). 

Rabbits  injected  with  diphtheria 
toxin  or  other  infectious  products, 
followed  by  injection  of  alcohol,  the 
results  confirming  the  clinical  obser- 
vations of  Dennig,  Hindelang,  and 
Griinbaum  in  respect  to  the  injurious 
action  of  alcohol  on  the  circulation 
during  febrile  conditions.  The  alco- 
hol improves  the  respiration,  but  this 
favorable  effect  is  outbalanced  by  its 
unfavorable  action  on  the  circulation, 
the  blood-pressure  dropping  and  the 
amplitude  growing  smaller,  although 
the  pulse  rate  may  remain  the  same. 
It  is  necessary  to  restrict  the  use  of 
alcohol  in  febrile  states,  weighing  in 
each  individual  case  whether  the  eu- 
phoria that  follows  the  use  of  alcohol 
outbalances  the  inevitable  somatic 
injury.  Alexandroff  (Corresp.-Blatt 
■f.  schweizer  Aerzte,  May  20,  1910). 

Impairment  of  the  vascular  regulat- 
ing mechanism  is  more  apparent  than 
active  disturbance  of  the  heart  in  the 
circulatory  derangements  of  the  acute 
infections.  Treatment  should,  there- 
fore, be  directed  to  the  prevention  or 
correction  of  these  vasomotor  dis- 
turbances, and,  while  alcohol  in  small 
doses  sometimes  acts  as  a  cardiovas- 
cular stimulant,  its  mode  of  action  is 
not  quite  clear.  In  larger  amounts,  in 
individuals  not  accustomed  to  its  use, 
it  invariably  acts  as  a  depressant, 
paralyzing  the  vasomotor  center.  The 
border  line  between  doses  that  act  as 
a  stimulant  and  those  which  act  as  a 
depressant  is  very  uncertain.  Some 
investigators  have  been  unable  to  de- 
tect a  rise  in  blood-pressure,  even 
with  very  moderate  doses,  and  this 
uncertainty  renders  it  an  undesirable 
therapeutic  agent.  Even  in  small 
doses  it  may,  and  in  large  doses  al- 
ways, depress  the  circulation,  and 
Other  drugs   more   constant  in   their 


action  are  advisable,  being  less  likely 
to  affect  the  patient  unfavorably.  J. 
L.  Miller  (Jour.  Amer.  Med.  Assoc, 
Dec.  10,  1910). 

Alcohol  is  frequently  used  to  in- 
crease the  warmth  of  the  body  surface 
in  the  presence  of  chilly  sensations  or 
after  exposure  to  cold.  This  is  accom- 
plished through  the  peripheral  vaso- 
dilation which  it  produces.  It  must 
not  be  forgotten,  in  this  connection,  that 
peripheral  vasodilation  results  in  in- 
creased heat  loss;  if,  during  exposure  to 
cold,  peripheral  vasodilation  be  pro- 
duced and  maintained  for  some  time,  as 
by  repeated  ingestion  of  alcohol,  the 
result  cannot  but  be  an  excessive  loss  of 
body  heat,  with  merely  temporary  re- 
lief, and  ultimate  lessening  of  the  resist- 
ing powers.  Hence  alcohol  to  warm  the 
body  surface  should  only  be  given  after 
exposure  or  just  before  the  period  of 
exposure  is  to  terminate. 

In  the  initial  stage  of  colds  and  of 
acute  catarrhal  inflammations  of  the 
respiratory  passages  in  general,  alco- 
holic preparations  have  been  much  used 
with  the  idea  that  by  sharply  activating 
the  circulation  of  blood  at  the  periphery 
local  congestions  will  be  relieved  and  the 
cold  thus  aborted.  The  patient  takes 
a  good-sized  dose  of  whisky,  followed 
by  smaller  doses  every  three  or  four 
hours,  and  stays  in  bed  for  a  day,  to 
facilitate  the  re-establishment  of  the 
circulatory  equilibrium.  While  there  is 
no  doubt  that  alcohol,  in  combination 
with  external  warmth,  will  often  bring 
about  the  desired  result,  the  same  ef- 
fect can  be  procured  by  means  of  a  hot 
bath,  a  coal-tar  drug,  and  a  saline  pur- 
gative, without  resorting  to  the  use  of 
alcohol. 

In  arteriosclerosis  alcohol  will  act  as 
a  vasodilator  and  doubtless  frequently 
performs  this  office  in  elderly  individuals 


1-S4 


530 


ALCOHOL    (SAJOUS). 


accustomed  to  its  use,  but  it  should 
never  be  prescribed  as  such  by  the 
physician. 

Where  the  eruption  is  delayed  in 
the  acute  exanthematous  diseases,  a 
dose  of  whisky,  taken  hot,  may  bring- 
about  its  early  appearance. 

As  a  Narcotic  and  Hypnotic, — The 
slightly  depressing  action  of  moderate 
doses  of  alcohol  on  the  cerebral  func- 
tions is  a  contributing  factor  in  its  use- 
fulness in  febrile  conditions.  Mild  de- 
lirium will  be  relieved  by  it,  or  if  no 
delirium  be  present  the  oncoming  of 
sleep  will  be  favored.  The  narcotic 
action  of  alcohol,  however,  is  only  of 
secondary  importance,  and  should  not 
be  utilized  unless  there  are  other  indica- 
tions for  the  use  of  the  drug.  In  febrile 
states  a  part  of  the  quieting  effect  on 
the  brain  is  due  to  a  lowering  of  the 
tension  in  the  cerebral  circulation 
through  the  general  vasodilation  which 
the  drug  produces. 

In  mild  degrees  of  insomnia  in  the 
aged,  a  little  alcohol  taken  before  retir- 
ing will  promote  sleep.  But  it  is  pref- 
erable to  use  other  remedies;  thus 
where  the  insomnia,  as  is  often  the  case, 
is  due  to  high  blood-pressure,  nitroglyc- 
erin should  be  substituted  for  alcohol,  as 
a  vasodilator.  A  mixture  of  equal  parts 
of  hot  milk  and  of  good  ale  or  beer  has 
been  recommended  as  a  promoter  of 
sleep. 

Although  alcohol  in  proper  dose  and 
in  the  proper  form  has  an  hypnotic 
effect  not  only  by  dilating  the  peripheral 
vessels  and  relieving  the  tension  of  the 
cerebral  circulation,  but  also  by  its 
quieting  effect  o  the  nervous  system,  it 
should  not -frequently  be  considered  or 
used  as  a  hypnotic.  Still,  instances 
occur  both  in  acute  illness  and  in  de- 
bilitated patients  vvrhere  it  seems  to  be 
the  safest  and  the  most  satisfactory  of 
hypnotics.  Of  course,  v^^hen  alcohol  is 
used  thus  as  a  drug  it  should  be  stopped 


by  the  physician  as  soon  as  he  considers 
that  the  patient  can  tolerate  another 
hypnotic,  or  that  the  positive  indication 
has  ceased  to  exist.  In  very  old  people 
who  cannot  sleep,  alcohol  as  a  "night- 
cap" has  been  frequently  advised. 
Sleeplessness  in  senility  is  frequently 
due  to  high-tension  circulation,  and  one 
can  often  cause  these  patients  to  sleep 
as  vi^ell  virith  small  doses  of  nitro- 
glycerin, administered  at  bedtime,  as  by 
alcohol  so  administered.  (Jour.  Amer. 
Med.  Assoc,  Nov.  6,  1909.) 

Similarly,  in  insomnia  in  greatly 
weakened  individuals,  where  alcohol 
may  seem,  for  a  time,  the  best  hypnotic 
to  use,  other  drugs  should  be  substi- 
tuted for  it  as  soon  as  the  patient's 
general  condition  permits.  Beer  or 
well-diluted  spirits  are  most  effective 
where  the  hypnotic  action  of  alcohol  is 
desired. 

In  neuralgia  as  well  as  melancholia 
and  other  forms  of  mental  distress  alco- 
hol has  given  relief  through  its  nar- 
cotic effect,  but  the  danger  of  inducing 
chronic  alcoholism  in  these  cases  is  such 
that  it  is  questionable  whether  it  should 
ever  be  employed. 

As  a  Stomachic,  Antemetic,  etc. — 
Ingested  before  or  during  meals,  alco- 
holic preparations  will  frequently  exert 
a  pronounced  beneficial  effect  in  cases 
of  atonic  dyspepsia  or  in  anorexia  or 
poor  digestion  due  to  physical  or  mental 
fatigue,  acute  illness,  etc.  A  small 
amount  of  wine  or  beer,  or  a  little 
brandy  diluted  with  water,  by  exerting 
a  mild  stimulating  eft'ect  locally  im- 
proves the  gastric  circulation  and  there- 
by promotes  the  secretory  activity  where 
this  is  deficient.  The  psychic  effect  of 
the  odor  and  taste  of  wine,  when  agree- 
able to  the  patient,  probably  also  plays 
a  not  inconsiderable  part  in  improving 
the  appetite.  Dry  wines  should  be 
given  the  preference  in  these  cases,  the 
sugar  of  sweet  wines  being  detrimental, 


ALCOHOL    (SAJOUS). 


531 


VVliere  anorexia  is  very  marked,  bitter 
tonics,  such  as  caltimba  or  quassia,  in 
the  form  of  tinctures  or  gentian  or  cin- 
chona, in  the  compound  mixtures,  may 
be  given  in  addition. 

In  certain  forms  of  indigestion,  alco- 
hol does  more  harm  than  good,  e.g., 
where  there  is  hyperacidity,  or  where 
the  gastric  mucosa  is  acutely  inflamed. 
In  all  cases,  moreover,  where  the  neces- 
■  sity  for  gastric  stimulation  is  likely  to 
persist,  e.g.,  in  the  chronically  debili- 
tated and  in  the  neurotic,  the  use  of 
alcohol  as  a  stomachic  and  stimulant  to 
digestion  is  to  be  entered  upon  only 
with  extreme  caution,  lest  chronic  alco- 
holism be  the  final  result.  This  danger 
is  less  to  be  feared  in  the  aged  than  it 
is  in  the  young  or  middle-aged. 

In  vomiting,  e.g.,  in  seasickness  and 
in  the  vomiting  of  pregnancy,  alcohol, 
especially  in  the  form  of  champagne, 
sometimes  proves  helpful.  A  little 
brandy  may  be  given  on  cracked  ice  in 
these  disturbances,  but  champagne  is 
decidedly  the  most  effective  preparation, 
combining  the  local  anesthetic  property 
of  alcohol  with  the  sedative  action  of 
carbon  dioxide  gas.  In  a  somewhat 
similar  manner,  the  pain  resulting 
from  flatulence,  as  well  as  gastralgia, 
may  be  relieved  by  the  use  of  brandy 
(Butler). 

In  diarrhea,  brandy  is  generally  be- 
lieved to  exert  a  favorable  influence, 
though  the  reason  for  its  beneficial  ef- 
fect is  not  known.  Red  wines,  by  virtue 
of  their  tannin  content,  also  tend  to 
counteract  diarrhea, — especially  Bor- 
deaux, dark  Burgundy,  and  currant 
wine. 

In  conditions  of  general  debility  and 
during  convalescence  from  exhausting 
diseases,  even  in  the  absence  of  gastric 
symptoms,  alcoholic  preparations  are 
frequently  given  as  general  stimulants 


and  reconstructives.  The  benefit  pro- 
duced results  in  part,  doubtless,  from 
activation  of  the  digestive  processes,  but 
the  food  value  of  the  preparations  used, 
generally  rich  red  wines,  such  as  port 
and  Madeira,  or  else  beer,  ale,  porter, 
brown  stout,  and  malt  extracts,  because 
of  the  additional  nutritive  substances 
they  contain,  must  also  be  given  due 
credit.  To  these  favorable  influences 
may  be  added  the  tendency  to  sleep  and 
rest  as  a  result  of  the  narcotic  action  of 
alcohol,  the  improved  distribution  of 
blood  through  peripheral  vasodilatation, 
the  lessened  resistance  to  cardiac  action 
offered  by  the  vessels,  and  the  euphoria 
of  the  primary  stage  of  alcoholic  action. 
In  severe  cases  of  diabetes  mellitus 
alcohol  has  also  been  used  as  a  food. 

Use  of  alcohol  as  a  food  in  cases  of 
severe  diabetes.    For  years  its  value  in 
such   cases   has   been   known   clinically. 
But  'until    recently    we    did    not    know 
whether  the  action  was  pharmacological 
or   whether  it   was  nutritive.     In   1906, 
Benedict    and    Torok,    in    studying    the 
origin    of    acetone    bodies    in    diabetes, 
substituted   the    fat    of    the    dietary    by 
alcohol   and   found   a   marked   decrease 
in    the    output    of    acetone,    sugar,    and 
nitrogen.     The    sugar    alone    decreased 
18  per  cent.     In  severe  cases  with  high 
ammonia    the    output    was    greatly    de- 
creased.     Their    work    added     further 
evidence   of   the   protein-sparing   action 
of   alcohol.      Neubauer,   simultaneously, 
found  alcohol  of  great  service  in  severe 
diabetes.     He    used    a    wine    containing 
10  per  cent,  alcohol,  allowing  daily   12 
to  24  ounces,   equivalent  to  450  to  900 
calories  of  energy.     He  found  regularly 
in  severe  cases  a  marked  reduction  in 
the  output  of  sugar,  acetone,  oxybutyria 
acid,  and  ammonia.     The  total  nitrogen 
and  the  amount  of  urine  were  decreased. 
In   light  cases  of  this   disease,   alcohol 
was   of    much    less    importance,    but    in 
severe  diabetes,  where  the  tissues  can- 
not utilize  carbohydrates,  where  only  a 
little  or  no  fat  is  allowable,  and  where 
protein   alone   tends   to    aggravate   the 


532 


ALCOHOL    (SAJOUS). 


conditions,  alcohol  finds  an  invaluable 
place  in  the  dietary.  Aside  from  its 
action  in  diabetes  and  a  few  conditions 
of  malnutrition,  there  has  been  no 
evidence  produced  thus  far  that  alcohol 
is  a  better  food  than  the  sugars  and 
starches.  There  is  some  reason  to 
believe  it  somewhat  inferior  to  them. 
There  is  abundant  evidence  that,  on 
account  of  its  habit-producing  power 
and  its  baneful  effects  when  used  in 
excess,  it  should  be  condemned  as  food 
for  healthy,  normal  individuals.  Scar- 
brough    (Yale  Med.  Jour.,  Feb.,   1910). 

As  a  Diuretic. — Dilute  gin,  light 
acid  white  wines,  and  light  beers  are  the 
most  strongly  diuretic  preparations  of 
alcohol.  This  property  can,  however, 
only  be  considered  as  a  relatively  unim- 
portant adjunct  to  the  other  actions  of 
alcohol. 

In  Phenol  Poisoning. — The  value 
/  of  alcohol  in  phenol  poisoning  has  been 
shown  to  be  due  to  the  ready  solubility 
of  the  phenol  in  it,  the  local  action  of 
phenol  in  concentrated  form  being 
thereby  hindered.  It  is  to  be  observed 
that  this  very  dilution  of  the  phenol  is 
likely  to  hasten  its  absorption  into  the 
general  system.  Hence  after  giving  the 
alcohol— preferably  dilute — the  physi- 
cian should  see  that  the  stomach  is 
emptied  as  soon  as  practicable. 

External  Uses.  —  Applied  locally, 
alcohol  has  antiseptic,  anesthetic,  cool- 
ing, stimulating,  solvent,  astringent, 
dehydrating,  and  hemostatic  proper- 
ties. It  is,  therefore,  a  valuable  agent 
in  the  treatment  of  wounds,  espe- 
cially infected  wounds,  in  the  man- 
agement of  which  whisky,  undiluted 
or  diluted  in  the  proportion  of  1  to  4 
of  water,  miay  be  employed  with  ad- 
vantage. In  snake-bites  concentrated 
alcohol  mixed  with  ammonia  may  be 
used  as  a  lotion  after  the  poison  has 
been  sucked  out;  it  is  similarly  use- 
ful   in    insect    stings.     In    puerperal 


sepsis  50  per  cent,  alcohol  has  been 
used  as  an  intra-uterine  douche,  and  in 
25  to  50  per  cent,  strength  as  a  packing; 
better  agents  are,  however,  at  our  dis- 
posal. 

For  the  treatment  of  sprains,  in- 
flamed joints,  contusions,  strained 
muscles  and  tendons,  headache,  neu- 
ritis, abscesses,  slight  burns,  ery- 
thema, and  erysipelas,  alcoholic  evap- 
orating lotions  are  extensively  used. 
A  lotion  composed  of  alcohol  8  parts, 
ammonium  chloride  1  part,  vinegar  or 
dilute  acetic  acid  4  parts,  in  water 
64  parts,  will  be  found  generally 
serviceable.  Where  a  greater  degree  of 
absorption  is  desired,  a  gauze  pad  may 
be  moistened  with  alcohol,  applied  over 
the  involved  area,  and  covered  with  rub- 
ber tissue.  In  phlegmonous  inflamma- 
tions, Salzwedel  cleanses  the  part  with 
ether,  applies  thick  layers  of  cotton 
saturated  with  90  per  cent,  alcohol,  and 
covers  the  whole  with  an  impermeable 
material,  perforated  in  such  manner  as 
to  delay,  but  not  entirely  prevent,  evapo- 
ration. By  this  plan,  he  states,  fever  is 
lowered  and  the  suppurative  process 
hastened.  Similarly,  in  sycosis,  furun- 
culosis,  indolent  ulcers,  whitlow,  etc., 
Heuss  employs  compresses  consisting  of 
6  to  8  folds  of  gauze  wet  with  95  per 
cent,  alcohol  and  covered  with  an  imper- 
meable dressing.  Kaiser  employed  alco- 
hol dressings  in  93  cases  of  various 
inflammatory  affections,  and  claimed 
very  gratifying  results;  the  distinctive 
feature  of  this  method  was  that  as  a 
preliminary  step,  all  fatty  matter  is  re- 
moved from  the  involved  area  with 
benzine  and  alcohol  (Bulkley). 

Permanent  applications  of  strong  al- 
cohol of  great  service  in  combating  all 
inflammatory  conditions  in  which 
there  is  a  tendency  toward  suppura- 
tion. It  causes  a  local  dilatation  of 
the    blood-vessels,    and    thereby    the 


ALCOHOL    (SAJOUS). 


533 


formation  of  alexins  and  consequent 
greater  capacity  for  resisting  the 
spread  of  infection.  Thick  layers  of 
gauze  are  saturated  with  alcohol  and 
then  covered  with  some  impervious 
material.  The  dressing  is  left  in  place 
for  days  at  a  time,  resaturating 
it  with  alcohol  once  every  twelve 
hours.  Graescr  (Miinch.  med.  Woch., 
July  17,  1900). 

Following  combination  recommended 
as  a  clean  and  effective  substitute  for 
the  ordinary  lead  and  laudanum  dress- 
ing:— 

IJ  Morphince  acetatis..  0.65  Gm.  (1  gr.). 
Liq.  plumbi  subace- 

tatis 30  c.c.    (1  oz.). 

'■AlcohoUs  ...q.  s.  ad  120  c.c.   (4  oz.). 

M.     Sig. :     Apply  on  1  layer  of  muslin 

or     cotton     and     allow     to     evaporate. 

W.  Brady  (N.  Y.  Med.  Jour.,  April  24, 

1909). 

The  benefit  derived  from  the  use  of 
the  tincture  of  arnica  in  sprains,  and 
spirit  of  camphor  in  mastitis,  seems  to 
depend  entirely  on  the  cooling  produced 
by  the  rapid  evaporation  of  the  alcohol 
contained  in  these  preparations.  The 
benefit  derived  from  the  popular  "alco- 
hol rub"  is  entirely  a  matter  of  sugges- 
tion, and  its  supposed  strengthening 
properties  are  mythical.  Alcohol  is  not 
absorbed  when  rubbed  on  the  skin. 
When  used  in  this  way  in  depressed 
conditions,  it  is  liable  to  do  harm,  by 
reducing  the  body  temperature  when  it 
should  be  sustained.  Olive  oil  or  cacao 
butter  should  be  used  instead  of  alcohol 
in  massage.  G.  A.  Graham  (N.  Y. 
Med.  Jour.,  May  8,  1909). 

Alcohol  recommended  as  a  final  ap- 
plication in  all  cases  of  wounds,  dress- 
ing with  either  plain  or  carbolized 
gauze.  In  bruises  and  sprains  equal 
parts  of  extract  of  witchhazel  and  al- 
cohol, applied  as  hot  as  can  be  borne, 
gives  much  better  results  than  liniments 
or  any  of  the  clay  and  glycerin  mix- 
tures, and  is  much  more  agreeable  to 
the  patient.  In  burns  and  scalds,  with 
suppuration,  alcohol  is  an  ideal  applica- 
tion, and  where  carbolic  acid  is  in- 
dicated it  can  be  used  in  any  strength 
if  followed  immediately  with  alcohol. 
This  also  applies  to  suppuration  in  all 


kinds  of  wounds.  In  patients  confined 
to  bed  for  any  length  of  time,  the  use 
of  alcohol  after  bathing  prevents  bed- 
sores. Alcohol  is  one  of  the  best  anti- 
septics to  clean  instruments  outside  of 
an  operating  room.  The  hypodermic 
needle  will  always  be  ready  if  kept  in 
alcohol,  and  there  will  be  no  need  of 
inserting  wires  in  it.  It  is  best  not  to 
use  a  weaker  solution  than  60  per  cent, 
of  alcohol.  Care  is  required,  however, 
to  get  pure  alcohol,  as  so  many  inferior 
brands  are  offered,  which,  if  used,  give 
disappointing  results.  S.  S.  Royster 
(Intern.  Jour,  of  Surg.,  Oct.,  1909). 

Reports  concerning  the  therapeutic 
uses  of  alcohol  in  dermatology  have 
recently  been  reviewed  by  Bulkley.  In 
eczema  Unna  recommends  an  alcohol 
dressing  having  the  following  composi- 
tion :  Sodium  stearate,  6  parts ;  glyc- 
erin, 2.5 ;  alcohol,  to  make  100.  This 
has  the  advantage  of  greater  perma- 
nency of  effect  than  the  rapidly  evapo- 
rating pure  alcohol,  can  be  employed 
where  the  application  of  a  bandage  is  im- 
practicable, is  non-irritating  and  strongly 
bactericidal.  In  herpes  simplex  as 
w^ell  as  herpes  zoster,  the  virtues  of 
alcohol,  applied  on  cotton  and  re- 
newed at  frequent  intervals,  vv^ere 
pointed  out  by  Leloir  and  Dupas;  if 
it  be  applied  in  the  stage  of  erythema 
the  eruption  w^ill  disappear  in  a  few 
hours ;  if  in  the  vesicular  stage,  in 
the  course  of  a  few  days.  Leloir 
recommends  that  a  small  quantity  of 
phenol  be  added,  in  order  to  alleviate 
further  the  burning  and  pain.  In 
lupus  erythematosus,  striking  results 
were  obtained  by  Hebra,  Jr.,  and  by 
Kohn  from  the  frequent  application 
of  alco'hol, — 40  to  50  times  daily. 
Continued  applications  of  alcohol  led 
to  cure  in  a  case  of  favus  reported  by 
Cantoni.  In  acne  rosacea,  Abrahams 
has  given  subcutaneous  injections  of 
20  to  30  drops  of  95  per  cent,  alcohol. 


534 


ALCOHOL    (SAJOUS). 


repeated  at  most  three  times  a  week, 
and  found  that,  after  a  temporary 
local  anemia,  the  injections  produced 
a  hyperemia  lasting  for  some  hours, 
by  which  obliteration  of  the  dilated 
vessels  could  be  secured,  providing 
the  treatment  be  kept  up  for  two  or 
three  months. 

In  frost-bite,  insect-bites,  and  itch- 
ing conditions  in  general  the  local 
anesthetic  property  of  alcohol  comes 
into  play.  According  to  Lauder 
Brunton,  the  itching  in  pruritus  ani 
can  be  checked  with  absolute  alcohol. 

In  sprains  and  contusions  a  rubefa- 
cient as  well  as  a  cooling  effect  is 
exerted. 

In  fever  the  body  temperature  may 
be  lowered  by  bathing  the  surface  with 
alcohol,  diluted  with  2  parts  of  water. 

Applied  to  aphthae  or  sluggish 
ulcers  of  various  kinds,  alcohol,  undi- 
luted, acts  as  a  stimulant  to  the  proc- 
esses of  repair. 

Used  hot  in  a  10  to  20  per  cent,  solu- 
tion, alcohol  has  long  been  used  as  a 
gargle  in  tonsillitis  and  pharyngitis. 

In  the  prophylaxis  of  bed-sores  and 
of  cracked  nipples,  dilute  alcohol  is 
very  effective  when  systematically 
rubbed  over  the  areas  exposed,  hard- 
ening the  skin  so  that  it  is  rendered 
more  resistant  to  external  influences, 
and  bringing  an  increased  amount 
of  blood  to  it,  thus  antagonizing 
local  necrosis.  Where  the  nipples 
are  already  the  seat  of  fissures  or 
excoriations,  alcohol  will  not  only 
tend  to  relieve  discomfort  by  obtunding 
the  sensory  nerve-endings,  but  will 
harden  the  surrounding  healthy  skin 
and,  by  coagulating  the  albumin  in  the 
secretions  of  the  raw  surfaces,  cover 
these  areas  with  a  thin,  protective  film. 
The  same  astringent  property  of  alcohol 
is  of  value  in  the  treatment  of  hyperi- 


drosis  (excessive,  sweating)  and  ten- 
der feet. 

As  a  hemostatic,  alcohol  is  of  some 
value  in  minor  hemorrhages,  espe- 
cially where  tiherq  is  merely  an  ooz- 
ing of  blood  from  ruptured  capillaries. 

As  a  solvent  of  fatty  substances,  and 
likewise  as  a  bactericidal  agent,  alcohol 
is  of  value  when  applied  to  the  hands 
and  operative  area  previous  to  minor 
surgical  procedures.  The  removal  of 
fatty  material  from  the  skin  surface 
facilitates  the  action  of  germicides,  such 
as  mercury  bichloride,  subsequently  ap- 
plied. According  to  von  Bruns,  the 
value  of  alcohol  in  the  preparation  of 
the  skin  before  operations  is  due  not 
alone  to  its  solvent  and  germicidal  prop- 
erties, but  also  to  the  fact  that  it  hardens 
the  skin  and  thereby  keeps  the  deeply 
lodged  bacteria  from  coming  to  its  sur- 
face. That  this  factor  in  the  action  of 
alcohol  is  not  in  reality  of  great  mo- 
ment, however,  would  seem  to  be  sug- 
gested by  the  recent  experimental  work 
of  Ritchie,  which  tends  to  minimize  the 
importance  of  the  sweat-glands  a*id 
hair-follicles  of  the  normal  skin  as 
restive  places  for  bacteria. 

A  dilution  of  alcohol  of  55 :  100  is 
toxic  to  staphylococci,  and  is  but 
slightly  inferior  to  1:1000  corrosive 
sublimate,  and  equal  to  carbolic  acid 
in  3  parts  per  100.  Alcohol  to  which 
is  added  an  alkali  for  the  purpose  of 
saponifying  fat  greatly  increases  the 
disinfecting  powers.  A  dilution  of  80 
parts  in  100  is  an  exceedingly  efficient 
disinfectant  for  the  hands.  G.  Fisher 
(La  presse  med.,  July  7,  1900). 

Property  of  alcohol  in  the  steriliza- 
tion of  the  hands.  It  is  in  abstracting 
air  from  the  pores  and  fissures  of  the 
skin  that  the  true  value  of  the  applica- 
tion lies ;  a  previous  treatment  with 
alcohol  enables  subsequent  aqueous 
solutions  to  penetrate  much  more  thor- 
oughly and  completely  into  all  the  mac- 
roscopical  and  microscopical  interstices 


ALCOHOL    (SAJOUS). 


535 


of      the      cutaneous      surface.      Rraatz 
(Miinch.  med.  Woch.,  July  17,  1900). 

In  the  various  preparations  of  alco- 
hol, those  with  a  higher  specific  weight 
have  more  energetic  disinfectant 
action.  The  most  energetic  prepara- 
tion is  40  per  cent,  alcohol,  which 
boils  at  about  90°  C.  Frank  (Miinch. 
med.  Woch.,  Jan.  22,  1901). 

Advantages  of  skin  disinfection  with 
alcohol  pointed  out.  If  the  skin  is 
bathed  and  shaved,  then  rubbed  for  five 
minutes  with  sterile  gauze  saturated 
with  absolute  alcohol,  its  disinfection  is 
accomplished  more  perfectly  than  by 
any  other  physical  or  chemical  method. 
Dehydrated  alcohol  or  wood  alcohol 
may  be  used  instead  of  pure  grain  alco- 
hol in  order  to  save  expense.  For 
effectiveness  it  is  essential  that  the  alco- 
hol used  be  nearly  or  quite  absolute 
alcohol.  Meissner  (Beitrage  z.  klin. 
Chir.,  S.  198,  1909). 

Experiments  with  von  Herff's  method 
of  disinfecting  the  hands  with  acetone 
alcohol.  It  is  thought  that  the  com- 
bination of  acetone  enables  the  mixture 
to  be  used  on  all  portions  of  the  body, 
and  attacks  the  fatty  tissue  and  disin- 
fects it  more  thoroughly  than  alcohol 
alone.  The  use  of  the  nailbrush  may 
be  omitted,  and  a  longer  disinfection  is 
obtained  by  this  method.  The  use  of 
soda  solution  for  ten  minutes  increases 
the  efficiency  of  the  method  somewhat. 
As  the  method  is  a  simple  one,  it  is 
especially  adapted  for  the  use  of  nurses 
and  midwives.  In  the  clinic  the  alcohol 
employed  was  95  per  cent.,  and  the  pro- 
portion of  acetone,  after  some  experi- 
ment, was  fixed  at  10  per  cent.  The 
most  efficient  combination,  however, 
seemed  to  be  that  of  SO  per  cent,  alco- 
hol and  SO  per  cent,  acetone.  Pre- 
liminary cleansing  with  soap,  water,  and 
brush  was  omitted.  Four  minutes  were 
occupied  in  disinfection.  The  method 
did  not  seem  to  irritate  the  skin,  and 
one  of  the  staff,  who  acquired  eczema 
through  other  methods  of  disinfection, 
was  much  improved.  Oeri  (Zeit.  f.  Geb. 
u.  Gyn.,  Bd.  Ixiii,  Hft.  3,  1908). 

Alcohol  used  as  a  disinfectant  found 
effect  for  a  short  time  only^for  opera- 


tions not  exceeding  five  minutes  in 
length.  Pfisterer  (Zeit.  f.  Geb.  u.  Gyn., 
Bd.  Ixiii,  Hft.  3,  1908). 

Comparative  study  made  of  the  value 
of  alcohol  and  of  Grossich's  iodine 
method.  The  two  methods  appeared 
equally  good,  though  the  iodine  method 
is  more  rapid.  In  the  alcohol  method 
the  hands  are  washed  with  soap  and 
water,  dried  with  a  towel,  then  scrubbed 
for  five  minutes  by  the  clock,  with 
gauze  wet  in  95  per  cent,  alcohol ; 
finally  the  hands  are  dried.  No  gloves 
are  worn.  During  the  operation  the 
hands  are  dipped  in  alcohol,  without 
trying  to  get  rid  of  the  blood  on  the 
hands,  which  are  blood-stained  at  the 
end  of  the  operation.  For  the  field  of 
operation  the  author  uses  alcohol  or 
tincture  of  iodine  on  the  dry  skin. 
There  is  no  previous  preparation,  with 
the  exception  of  a  bath  the  night  be- 
fore. Grekow  (Arch.  f.  klin.  Chir.,  S. 
1073,  1909). 

Two  years'  experience  has  demon- 
strated to  the  author's  satisfaction  the 
superi6rity  of  this  simple  and  con- 
venient method  over  all  other  techniques 
in  which  soap  and  water  are  permitted. 
He  rubs  the  field  of  operation  for  five 
minutes  with  the  10  per  cent,  alcohol 
acetone  solution  and  then  applies  a  var- 
nish, the  formula  for  which  is  10  parts 
each  of  benzoin  and  dammar  resin  in 
100  parts  ether,  stained  with  20  per 
cent,  of  an  alcohol  iodoiodide  solution 
(7  parts  iodine,  5  parts  potassium  iodide 
and  100  parts  alcohol).  Von  Herff 
(Therap.  der  Gegenwart,   Dec,   1909). 

Comparative  tests  of  various  methods 
of  sterilization  performed.  A  5  per 
cent,  alcohol  solution  of  tannin  sur- 
passes all  the  other  techniques  with  the 
exception  of  tincture  of  iodine;  it 
ranks  with  this,  while  it  is  free  from  its 
disadvantages.  The  tannin  solution  is 
applied  to  the  hands  for  two  minutes 
and  to  the  field  of  operation  for  one 
minute ;  the  previous  use  of  water  does 
not  affect  it.  Zabludowski  (Deut.  med. 
Woch.,  March  2,  1911). 

Finally,  the  value  of  alcohol  as  a  pre- 
ventive and  curative  aerent  in  carbolic 


536 


ALCOHOL    (SAJOUS). 


acid  burns  is  well  recognized.     The 
phenol  is  dissolved  by  the  alcohol. 

Efficiency  of  alcohol  as  an  antidote  to 
carbolic  acid  questioned.  According  to 
experiments  high  concentrations  of  al- 
cohol and  low  concentrations  of  carbolic 
acid  seemed  to  increase  the  toxicity  of 
the  latter.  A  1 :  100,000  solution  of 
carbolic  acid  was  more  toxic  in  the 
presence  of  10-per-cent.  alcohol  than 
without  it.  The  antagonism  of  alcohol 
to  carbolic  acid  observed  in  practice 
probably  depends  on  a  physical  rather 
■  than  a  chemical  basis.  Taylor  (Jour. 
of  Biol.  Chem.,  Dec,  1908). 

The  peculiar  phenomena  by  reason  of 
which  alcohol  has  been  acclaimed  an 
antidote  to  phenol  are  the  result  of 
its  solvent  and  repellent  properties 
and  not  of  any  chemical  antagonism. 
Phenol,  though  a  powerful  corrosive, 
limits  its  destructive  progress  by  the 
formation  of  an  albuminous  coag- 
ulum.  Alcohol  is  of  great  value 
externally  when  used  early,  but  when 
used  late  the  destruction  of  tissue  is 
not  prevented,  although  the  appear- 
ance is  better.  On  account  of  the 
repellent  and  solvent  properties  of 
alcohol  it  is  dangerous  to  leave  it  in 
the  stomach  together  with  the  phenol. 
The  treatment  advised  is,  first,  lavage 
with  some  solution,  as  the  magnesium- 
sulphate,  albumin  mixture,  followed  by 
lavage  with  a  solution  of  alcohol  as  a 
clearing  agent.  Novack  (Mo.  Cyclo. 
and  Med.  Bull.,  Aug.,  1909). 

Internally,  there  are  but  five  indica- 
tions for  alcohol  that  justify  its  use 
under  our  present  knowledge:  (1)  As 
an  antidote  to  carbolic  acid — only 
when  it  can  be  administered  shortly 
— within  one  or  one  and  a  half  hours 
— following  the  poison.  Life  saved 
in  two  instances  by  this  measure. 
Diluted  alcohol  (50  per  cent.)  is 
better  than  brandy  and  whisky.  (2) 
As  a  fuel,  in  fevers,  exhausted  states 
of  the  body,  and  marasmus  of  infants. 
Here  our  purpose  must  be  to  give 
only  a  quantity  that  the  patient  can 
metabolize  or  oxidize  and  derive 
therefrom  energy.  When  we  can 
detect    alcohol    on    the    breath,    the 


dose  must  be  decreased.  An  average 
dose  of  alcohol  for  this  purpose  is  2 
to  4  c.c.  (4  to  8  c.c.  whisky;  30  c.c. 
or  less  of  wine,  according  to  variety; 
10  to  30  c.c.  of  any  of  the  "medicinal" 
proprietary  foods),  given  every  four  to 
six  hours,  with  or  following  other  food, 
preferably.  (3)  For  the  chill  of  fe- 
brile stages — such  as  pneumonia,  ma- 
laria, septicemia — here  alcohol  in 
medicinal  dose  {e.g.,  15  c.c.  or  more 
of  whisky)  opens  the  surface  capil- 
laries that  are  contracted  in  chill  and 
so  gives  a  sense  of  warmth  to  the 
patient,  lowers  the  fever,  and  through 
cerebral  depression  blunts  the  pa- 
tient's mental  anguish.  Of  course, 
the  chill  of  hemorrhage,  shock,  or 
other  condition  not  accompanied 
with  fever  contraindicates  alcohol.  (4) 
To  reduce  fever.  In  some  cases  of 
typhoid,  where  the  plunge  or  sponge 
bath  fails  to  lower  an  excessive  tem- 
perature, 30  c.c.  of  brandy  immediately 
preceding  the  bath  will  insure  a  notable 
reduction,  by  driving  the  warm  blood  to 
the  surface  to  be  returned  cooled  to  the 
internal  organs.  In  the  presence  of  a 
low  arterial  tension  or  a  very  weak 
heart  muscle,  however,  this  use  of  alco- 
hol would  hardly  be  justified.  (5)  As 
a  narcotic,  in  many  persons  of  ad- 
vanced years  and  a  few  with  earlier 
arteriosclerosis  who  are  apt  to  suffer 
from  insomnia,  a  "night-cap"  of 
brandy  in  the  form  of  a  "sling"  will 
act  favorably  and  is  free  from  the 
unpleasant  sympjtoms  that  often  fol- 
low the  use  of  the  old  or  new  hyp- 
notics. Fear  of  habit,  in  this  in- 
stance, need  hardly  be  considered. 
Prescribing  alcohol  to  enable  a  pa- 
tient to  withstand  the  strain  of 
having  a  tooth  extracted,  an  abscess 
opened,  or  wound  sutured,  on  the  other 
hand,  is  crude  therapeutics.  William 
Brady  (N.  Y.  Med.  Jour.,  April  24, 
1909). 

Alcohol  Injections. — Neuralgia  and 
Neuritis. — Injections  of  alcohol  into 
or  in  the  vicinity  of  nerve  trunks  for 
the  purpose  of  relieving  pain  are  em- 
ployed particularly  in  trifacial  neural- 
gia (tic  douloureux)  and  in  sciatica. 


ALCOliUL    (SAJOUS). 


537 


but  have  also  been  utilized  in  intract- 
able neuralgias  of  other  nerves,  in 
neuritis  following  influenza,  in  bleph- 
arospasm, and  recently  in  laryngeal 
tuberculosis. 

The  Schlosser  plan  of  injection  in  tic 
douloureux,  viz.,  the  injection  of  alco- 
hol into  the  second  or  third  divisions  of 
the  trifacial  nerve  at  their  emergence 
from  the  cranium,  has  been  extensively 
tested  and,  owing  to  the  prompt  benefit 
it  affords,  is  growing  in  favor,  though 
it  cannot  be  considered  as  a  uniformly 
curative  measure,  a  certain  number  of 
cases  relapsing  after  a  variable  number 
of  months  of  freedom  from  pain.  The 
mode  of  action  of  the  alcohol  in  these 
cases  was  elucidated  in  1910  by  Schlos- 
ser, who  found  through  animal  experi- 
mentation that  alcohol  of  70  to  80  per 
cent,  concentration,  when  brought  in  re- 
lation with  a  nerve,  caused  degenerative 
processes  to  take  place  in  all  the  ele- 
ments of  the  nerve  except  the  neu- 
rilemma. Leszynsky,  reporting  15 
cases  of  tic  douloureux  successfully 
treated  by  a:lcohol  injection,  stated  his 
belief  that  this  method  is  practically 
equivalent  to  a  section  of  the  nerve, 
with  the  added  advantage  of  absence  of 
an  operative  scar.  The  method  is  not 
applicable,  however,  to  neuralgia  of  the 
first  division  of  the  trifacial,  a  certain 
amount  of  danger  having  been  found  to 
attend  injections  of  this  branch. 

Report  of  63  cases,  41  women  and  22 
men,  in  which  alcohol  injections  were 
given.  In  21  cases  the  second  divisions 
were  involved,  in  31  cases  the  first  and 
second  divisions,  and  in  11  cases  the 
second  division  alone.  As  regards  re- 
sults, the  cases  were  divided  into  two 
classes:  (1)  those  previously  treated 
surgically;  (2)  those  not  so  treated. 
The  cases  of  the  first  class  were  not 
half  as  much  benefited  by  alcohol  in- 
jection as  those  of  the  second.  In  1 
case,  previously  operated  upon  at  three 


different  times,  no  effect  on  the  pain 
was  produced  until  the  branches  of  the 
trigeminal  on  the  sound  side  had  been 
injected.  With  the  exception  of  2 
cases  the  results  were  uniformly  good. 
Three  of  the  cases  had  already  re- 
mained well  from  eighteen  months  to 
two  years.  In  most  cases  the  treat- 
ment must  be  resumed  at  the  end  of 
six  months,  but  recurrences  are  apt  to 
be  less  severe  each  time  they  appear. 
Sicard   (Presse  med..  May  6,  1908). 

Report  of  190  cases  of  trifacial  neu- 
ralgia injected  with  alcohol  since  1906. 
The  number  of  injections  varied  from 
2  to  10,  the  average  being  3.  Results : 
S  failures  and  185  cases  free  from  pain 
for  varying  periods.  Kiliani  (Med. 
Record,  June  5,  1909). 

Alcohol  injections  given  in  75  cases 
of  unmistakable  tic  douloureux,  in- 
variably with  relief.  Thirty-six  pa- 
tients were  between  60  and  70  years  of 
age,  13  between  70  and  80  years,  and  1 
over  80  years.  All  the  patients  had  al- 
ready tr.ied  other  forms  of  treatment 
and  a  considerable  number  had  under- 
gone operation.  Alcohol  of  85  per  cent, 
strength  was  used,  4  grains  of  cocaine 
to  the  ounce  being  added.  About  2  c.c. 
of  the  solution  were  injected  each  time. 
The  injections  were  made  with  a 
straight  needle  about  10  cm.  long,  1.5 
mm.  thick,  and  fitted  with  a  stylet  or 
obturator,  the  blunt  end  of  which  was 
flush  with  the  needle-point.  The  sharp 
point  was  used  to  puncture  the  skin, 
after  which  the  stylet  was  pushed  home, 
making  a  blunt  instrument  for  the  re- 
mainder of  the  penetration.  The  needle 
is  introduced  at  the  lower  border  of  the 
zygoma,  the  aim  being  to  attain  the 
inferior  maxillary  division  of  the  nerve 
at  the  emergence  from  the  foramen 
ovale  (about  4  cm.  in  depth),  and  the 
superior  as  it  leaves  the  foramen  rotun- 
dum.  Patrick  (Jour.  Amer.  Med.  As- 
soc, Dec.   11,   1909). 

Laryngeal  Tuberculosis. — Alcohol 
injections  into  the  superior  laryngeal 
nerve  for  the  reHef  of  dysphagia  in 
tuberculosis  of  the  larynx  were  intro- 
duced by  Hoffman,  of  Munich.    Recent 


538 


ALCOHOLISM    (CROTHERS). 


experiences  with  this  procedure  have 
only  served  to  confirm  and  establish  its 
usefulness  as  a  palliative  measure. 

Alcohol  injections  into  superior  laryn- 
geal nerve  employed  in  a  series  of 
cases  with  gratifying  results.  The 
duration  of  the  relief  experienced  is  the 
striking  feature  of  this  method  of  treat- 
ment. The  solution  employed  consists 
of  2  grains  of  hydrochloride  of  beta- 
eucaine  in  an  ounce  of  80-per-cent.  alco- 
hol. The  patient  being  placed  horizon- 
tally, the  sound  side  of  the  larynx  is 
pressed  toward  the  middle  line  with 
the  thumb  of  the  left  hand  so  that  the 
affected  half  projects  distinctly;  the 
other  fingers  of  the  hand  lie  on  this 
half.  The  index  finger  enters  the 
space  between  the  thyroid  cartilage  and 
the  hyoid  bone  from  without  until  the 
patient  announces  that  a  painful  spot 
has  been  reached.  The  nail  of  the  in- 
dex finger  is  now  placed  upon  the  skin 
in  such  a  way  that  the  point  of  entrance 
for  the  needle  lies  oposite  its  middle. 
The  needle  is  pushed  in  for  about  1.5 
cm.;  this  distance  is  marked  off  on  the 
needle  perpendicularly  to  the  surface  of 
the  body.  According  to  the  thinness  of 
the  subcutaneous  layer  of  fat,  the  per- 
foration has  to  be  more  or  less  deep. 
The  needle  is  then  carefully  moved  so 
as  to  seek  a  spot  at  which  the  patient 
feels  pain  in  the  ear.  The  syringe,  filled 
with  the  alcohol,  warmed  to  a  tempera- 
ture of  45°  C.  (113°  F.),  is  screwed  to 
the  needle  and  the  piston  slowly  pressed 
down.  The  patient  now  feels  pain  in 
the  ear,  the  passing  off  of  which  he 
indicates  by  raising  his  hand.  During 
the  operation  swallowing  and  speaking 
must  be  avoided.  The  injection  is  kept 
up  until  no  further  pain  occurs  in  the 
ear.  Then  the  needle  is  removed  and 
collodion  applied.  The  point  of  the 
needle  is  bevelled  much  more  obtusely 
than  the  ordinary  hypodermic  needle,  to 
avoid  the  danger  of  puncturing  a  A^es- 
sel.  Dundas  Grant  (Lancet,  June  25, 
1910). 

Tumors. — Carcinoma  of  the  uterus 

was  treated  with  alcohol  as  long  ago  as 
1878   by   Hasse,   who  made   injections 


into  the  circumference  of  the  tumors  in 
3  cases  with  good  results ;  after  twenty- 
three  years  the  patients  were  alive  and 
well.  Obliteration  of  the  Blood-vessels 
and  shrinkage  of  the  tumor  were  found 
to  have  taken  place,  through  connective- 
tissue  proliferation  around  the  growth. 
A  similar  plan  of  treatment  has  also 
been  utilized  in  cancer  of  the  breast. 
As  a  palliative  measure,  interstitial 
injections  of  alcohol  were  used  by 
Vulliet,  of  Geneva,  in  inoperable  cases 
of  uterine  cancer.  The  benefit  ob- 
tained was  ascribed  by  him  to  the 
local  ischemia  induced. 

C.  E.  DE  M.  Sajous 

AND 

L.  T.  DE  M.  Sajous, 

Philadelphia. 


ALCOHOLIC  NEURITIS. 

Neuritis. 


See 


ALCOHOLISM,  OR  ALCOHOL 
INEBRIETY.  —DEFINITION.— 

Alcoholism  is  frequently  defined  as 
the  result,  in  the  organism,  of  excessive 
consumption  of  alcohol.  The  term,  thus 
interpreted,  should  refer  only  to  indi- 
viduals profoundly  poisoned  and  dis- 
eased from  this  specific  cause.  Mod- 
ern research  has  shown,  however,  that 
there  exists  a  large  class  of  cases  in 
Avliich  the  excessive  use  of  alcohol  is 
a  predominant  feature,  but  which  are 
not  accurately  described  by  the  term 
"alcoholism,"  viz.,  those  in  which  the 
use  of  spirits  is  only  symptomatic  of  a 
neurosis  of  different  nature  and  causa- 
tion. It  is  probable  that  at  least  50  per 
cent,  of  all  so-called  alcoholics  have 
suffered  from  disease  of  the  nervous 
system  before  acquiring  the  alcoholic 
habit. 

Inebriety,  meaning  a  poisoned  or 
stuporous  state  directly  or  indirectly 
the  result  of  alcohol,  is,  in  reality,  a 


ALCOHOLISM    (CROTllERS). 


539 


more  general  term  than  "alcoholism," 
since  it  refers  to  the  condition  of  all 
those  who  use  alcohol  to  excess.  This 
term  is  also  emj^loyed,  however,  to  des- 
ignate toxic  states  resulting  from  the 
use  of  various  other  drugs,  such  as 
opium,  cocaine,  chloral,  chloroform, 
etc. 

[Alcoholism  received  very  little  attention 
as  a  distinct  malady  until  recent  times.  Yet, 
there  is  abundant  evidence  that  the  excessive 
use  of  wine  and  beer  was  recognized  as  a 
disease  in  the  civilization  of  Egypt  at  least 
seven  or  eight  thousand  years  ago.  This 
belief  existed  also  in  early  Grecian  times, 
and  some  very  acute  reasonings  as  to  the 
causes  and  means  of  prevention  were  brought 
forth,  although  wine  was,  nevertheless,  de- 
fined as  a  means  of  inducing  a  supposed 
highly  esthetic  condition  of  the  mind.  In 
later  j^ears,  when  alcoholism  became  wide- 
spread, and  was  given  place  among  the 
great  national  vices,  many  physicians  began 
to  consider  it  as  a  disease  and  a  curable  one, 
and  laws  were  passed  based  on  the  recog- 
nition of  this  fact. 

Although  the  physical  nature  of  inebriety 
had  been  recognized  in  many  directions  and 
fragmentary  statements  concerning  it  had  ap- 
peared in  foreign  literature,  it  was  reserved 
for  Dr.  Benjamin  Rush,  of  Philadelphia,  to 
give  it  a  permanent  setting  in  a  small  book 
published  in  1S09.  He  urged  that  alcoholism 
was  a  disease  curable  and  preventable.  The 
medical  interests  of  the  subject  seem  to  have 
dated  from  this  point.  Although  many 
foreign  authors  have  given  very  minute 
descriptions  of  the  pathological  effects  of 
alcohol  on  the  body,  the  disease  of  inebriety 
or  alcoholism  has  been  given  but  little  at- 
tention. To.  American  physicians,  therefore, 
is  very  largely  due  the  promotion  of  this 
idea. 

The  creation  of  an  institution  at  Bingham- 
ton,  New  York,  in  1864,  for  the  treatment 
of  inebriety  as  a  disease  brought  the  subject 
into  prominence,  and  gave  permanence  to 
the  belief  which  had  persisted  in  the  midst 
of  more  or  less  uncertainty  through  all  the 
centuries  past.  The  organization  of  a  society 
for  the  study  of  the  subject,  and  the  publica- 
tion of  a  journal  as  its  organ,  still  further 
developed,    and    brought    into    public    notice. 


this  great  question.  Though  sharply  con- 
demned at  first,  and  pronounced  an  extreme 
and  untenable  view,  it  has  grown  to  be  a 
settled  fact,  accepted  in  practically  all  cen- 
ters of  scientific  inquiry,  that  the  inebriate 
and  alcoholic  is  suffering  from  a  distinct 
neurosis — a  disease  requiring  special  study 
and  treatment. 

During  the  last  half-century  a  consider- 
able literature  on  this  subject  has  appeared, 
much  of  it  merely  formative  and  dogmatic, 
but  clearing  the  way  and  establishing  funda- 
mental principles  for  a  more  rational  view 
and  explanation  of  the  morbid  processes 
entailed. 

The  amount  of  alcohol  consumed  per 
capita  has  been  increasing,  and  it  is  fair  to 
judge  that  this  indicates  an  increased  num- 
ber of  persons  to  be  suffering  from  the  dis- 
ease produced  by  it.  Researches  into  the 
etiology  of  various  maladies  show  that  as  a 
source  of  degeneration  and  as  a  contribut- 
ing cause  the  use  of  alcohol  is  a  very  promi- 
nent factor. 

Whether  there  are  more  alcoholics  than 
formerly,  meaning  by  this  persons  who  are 
notoriously  "affected  by  the  use  of  spirits, 
is  an  open  question.  Many  are  convinced 
that  the  number  of  inebriates  or  alcoholics 
is  diminishing,  and  this  would  appear  to  be 
true  from  a  mere  casual  observation.  Fewer 
men  are  arrested  for  drunkenness  on  the 
streets,  while  the  number  of  persons  who 
are  in  the  incurable  stages  apparent  to  all 
is  diminishing. 

It  IS,  nevertheless,  evident  that  the  mor- 
tality among  persons  who  drink  alcohol  has 
greatly  increased,  and  that  it  is  not  possible 
in  this  country  to  drink  alcohol  in  so-called 
moderation,  according  to  the  European 
standards.  This  is  illustrated  by  the  fre- 
quency and  extreme  fatality  of  pneumonia  in 
alcoholics.  Cerebral  hemorrhage  is  another 
common  sequela,  and  is  given  as  the  cause  of 
death  in  a  large  proportion  of  cases  with  an 
alcoholic  history.  Nephritis  and  cirrhosis 
are  other  familiar  causes  of  death  in  persons 
addicted  to  alcohol.  The  mortality  in  all 
these  diseases  being  high,  it  is  evident  that 
alcohol  is  a  dangerous  beverage  and  drug. 

The  high  degree  of  mental  activity  and 
nervous  strain  characteristic  of  American 
civilization  has  much  to  do  with  intensifying 
the  toxic  action  of  alcohol  and  lowering  the 
resisting   power   and   vitality.      The    average 


540 


ALCOHOLISM    (CROTHERS). 


American  business  man,  too,  is  far  more 
susceptible  to  the  poisonous  effects  of  alco- 
hol than  individuals  of  the  same  class  in 
Europe. 

On  the  whole,  alcoholism  in  America  is 
a  far  more  serious  and  fatal  disease  than  in 
any  other  country.  The  results  from  the 
i:se  of  spirits  are  more  destructive,  and  the 
injury  less  easily  repaired.  Alcohol  is  a  more 
grateful  and  fascinating  narcotic  in  America 
than  elsewhere,  because  it  produces  seductive 
effects  of  relief,  and  covers  up  exhaustion. 
The  enormous  sale  of  proprietary  drugs 
containing  alcohol  is  evidence  of  this.  Even 
in  colleges  and  training  schools  many  young 
men  are  impressed  with  the  accuracy  of  the 
old-time  theory  that  alcohol  has  a  stimulant 
and  invigorating  action,  and  use  it  upon  the 
advice  of  their  teachers  or  from  the  con- 
tagion of  their  associates. 

On  the  whole,  the  fact  is  becoming  more 
and  more  prominent  not  that  alcoholism  is 
of  greater  prevalence,  and  the  victims  more 
numerous,  but  that  any  use  of  alcohol  is 
d,angerous  to  both  brain  and  muscle  workers, 
and  is  obstructive  to  all  success  and  prog- 
ress in  every  department  of  life.  T.  D. 
Ceothers.] 

Alcohol  really  plays  an  enormous 
role  in  bringing  about  degeneration  of 
the  race.  This  is  most  clearly  seen  in 
the  growing  inability  of  mothers  to 
nurse  their  offspring;  thus,  when 
mother  and  daughter  of  one  family 
were  not  obliged  to  resort  to  artificial 
feeding,  the  father  was  a  drunkard  in 
only  2.6  per  cent,  while,-  where  both 
were  unable  to  nurse,  a  history  of  ex- 
cessive drinking  was  obtained  in  42.2 
per  cent.  All  cases  of  functional  de- 
rangement owing  to  imperfect  condi- 
tion of  the  nipples  were  ruled  out. 
The  condition  is  hereditary,  for  if  the 
mother  has  lost  the  power  it  will  never 
be  regained  in  that  particular  genera- 
tion. 

Other  stigmata  go  hand  in  hand  with 
deficient  nursing  capacity,  and  a  pro- 
nounced disposition  toward  tubercu- 
losis, nervous  diseases,  and  psychoses 
is  very  evident.  The  offspring  of  alco- 
holics also  suffer  more  frequently 
from  carious  teeth.  G.  v.  Bunge  (Vir- 
chow's  Archiv,  Bd.  clxxv,  Nu.  2,  1904). 


TOXICITY  OF  THE  ALCO- 
HOLS.— All  alcohols  are  poisonous, 
though  their  toxic  power  varies  con- 
siderably in  accordance  with  the  va- 
riety of  alcohol  ingested.  Thus,  the 
heavier  members  of  the  series  (pro- 
pyl, butyl,  and  amyl  alcohols),  which 
have  a  higher  boiling  point  than  ordi- 
nary ethyl  alcohol,  are  more  toxic 
than  the  latter.  Methyl  alcohol, 
though  the  lightest  of  all  the  alco- 
hols, is,  nevertheless,  more  poisonous 
than  ethyl,  forming  an  exception  to 
the  general  rule  that  the  toxicity  of 
the  alcohols  rises  with  the  increase 
in  their  molecular  weights.  The 
toxic  action  of  methyl  alcohol,  or  "wood 
spirits,"  has  already  been  described  {v. 
Methyl  Alcohol).  That  of  ethyl 
alcohol,  which  forms  the  subject  of  this 
article,  is  modified,  to  a  certain  extent, 
by  the  nature  of  the  preparation  con- 
taining it.  Spirits  exert  a  more  rapid 
toxic  effect  than  wines  or  beers,  owing 
to  the  greater  concentration  and  quan- 
tity of  alcohol  present  in  the  former. 
The  different  kinds  of  spirits  them- 
selves exhibit  differences  in  toxicity  in 
accordance  with  the  material  from 
which  they  are  produced,  the  variations 
being  due  to  differences  in  the  amount 
of  certain  additional  toxic  compounds 
contained,  such  as  aldehyde,  ketones, 
furfurol,  ethers,  etc.  Thus,  according 
to  Dujardin-Beaumetz  and  Audige, 
spirits  made  from  wine  (brandy)  are 
the  least  toxic;  next  follow  in  or- 
der spirits  made  from  perry,  cider, 
grain,  beets,  and  molasses;  finally 
come  spirits  made  from  potatoes  and 
sorghum,  which  are  the  most  toxic, 
owing  to  the  relatively  large  pro- 
portions of  isobutylic  and  amylic  al- 
cohols they  contain.  Spirits  of  in- 
ferior grade  are  especially  dangerous 
because  they  are  made  with  impure 


ALCOHOLISM    (CROTIIERS). 


541 


alcohol,  the  disagreeal)le  taste  and 
odor  of  the  impurities  being-  masked 
by  admixture  of  artificial  flavors  and 
essences  (Pouchet).  In  addition  to  the 
true  spirituous  liquors  already  referred 
to,  there  is  a  large  group  of  liquors 
representing  a  solution  of  various  aro- 
matic principles,  either  of  vegetable 
origin  or  produced  synthetically,  in  a 
menstruum  of  alcohol.  Here  the  ef- 
■fects  of  the  aromatic  principles  are 
added  to  those  of  alcohol,  and  these 
fluids  may,  therefore,  be  divided  into 
two  groups,  according  as  the  tendency 
of  the  aromatic  principle  contained  is 
to  produce  epileptiform  convulsions 
(best  illustrated  in  the  case  of  ab- 
sinthe), or  to  bring  on  stupor  (anise, 
mint,  angelica,  etc.). 

The  fatal  dose  of  alcohol  varies 
within  wide  limits.  The  factors  influ- 
encing it  include  not  only  the  individ- 
ual's habits  with  respect  to  alcoholic 
indulgence,  but  in  addition  his  state 
of  health,  the  climate  and  tempera- 
ture, and  the  rapidity  of  absorption 
(Pouchet).  The  average  lethal  dose 
has  been  stated  to  be  60  to  180  Gm. 
(2  to  6  ounces,  approximately).  Less 
than  1  pint  of  whisky  has  sufBced  to 
cause  the  death  of  an  adult.  In  the 
lower  animals,  Lussana  and  Albertoni 
give  6  Gm.  (V/2  drams)  per  kg.  of 
body  weight  as  the  minimum  lethal 
■dose. 

VARIETIES.  — There  are  two 
forms  of  alcoholism:  (1)  the  acute,  in 
which  alcoholic  poisoning  is  speedily 
manifested  in  active  excitement  and 
disturbance,  or  in  which  a  sudden  ex- 
acerbation of  the  disorders  attending 
the  chronic  type  gives  rise  to  a  corre- 
spondingly marked  symptomatic  activ- 
ity; (2)  the  chronic,  in  which  the 
continued  ingestion  of  alcoholic  bever- 
ages    in     more     or    less     considerable 


amounts  sets  up  gradually  progressing 
pathological  changes  in  the  various 
organs  and  tissues,  thereby  giving  rise 
to  chronic  disorders  of  each  of  the 
parts  thus  affected. 

Under  acute  alcoholism  are  to  be 
considered  not  only  acute  alcoholic 
poisoning,  intoxication,  or  "drunken- 
ness," but  also  acute  alcoholic  epilepsy, 
acute  alcoholic  hysteria,  acute  alcoholic 
delirium  or  delirium  tremens,  and  acute 
alcoholic  mania  or  mania  a  potu. 

ACUTE  ALCOHOLISM. 

DEFINITION.  — A  condition  re- 
sulting from  the  ingestion,  within  a 
short  period,  of  alcohol  in  sufficient 
quantity  to  produce  exaggerated 
physiological  effects  or  actual  poison- 
ous effects.  The  amount  required 
to  intoxicate  varies  widely  according 
to  the  natural  susceptibility  of  the  in- 
dividual, and  to  whether  or  not  his 
organisni  has  become  accustomed  to 
the  action  of  alcohol  through  re- 
peated use. 

SYMPTOMS.— Three  stages  are 
discernible  in  this  condition :  The  first 
is  that  of  beginning  vascular  relaxation 
and  primary  excitation.  The  intoxi- 
cated individual  is  usually  lively,  merry, 
agile,  and  joyous ;  all  excitement  and 
energy;  in  the  highest  spirits,  cheerful, 
hopeful,  and  communicative ;  mercurial 
and  confiding,  often  telling  of  his  pri- 
vate affairs  to  strangers.  There  is  a 
warm  glow  on  his  countenance,  and  he 
appears  at  his  best.  Gradually  his  spir- 
its rise  still  higher;  he  becomes  more 
demonstrative  in  love  or  in  argument, 
more  emphatic  in  his  gestures,  more 
furious  in  his  fun,  and  very  much 
louder  in  his  laughter  as  the  second 
stage  is  ushered  in.  With  this  he  be- 
comes much  less  reasonable  and  amen- 
able, incoherence  of  thought  and  speech 
gradually  sets  in,  the  imagination  rev- 


542 


ALCOHOLISM    (CROTHERS). 


els,  exaggeration  is  a  prominent  fea- 
ture, and  the  emotions  dominate  the 
subject,  intellect,  reason,  will,  and  con- 
science rapidly  fading  into  the  back- 
ground. In  some  cases  his  thoughts, 
speech,  and  actions  are  exaggerated.  In 
other  instances  they  are  transformed, 
the  habitually  modest,  retiring  man  be- 
coming a  boaster  and  a  braggart,  the 
truthful  a  liar,  the  meek  violent.  With 
all  this,  the  speech  thickens,  the  lower 
and  then  the  upper  limbs  cease  to  act 
in  unison;  the  intoxicated  cannot 
stand,  but  staggers  with  a  paralytic  un- 
steadiness, the  muscles  becoming  flabby 
and  feeble.  The  third  stage,  that  of 
"dead  drunkenness,"  reveals  the  sub- 
ject unconscious,  with  the  pallor  of  ap- 
parent death  on  the  face,  extreme  cold- 
ness of  the  skin,  accompanied  by  total 
insensibihty,  and  an  utter  disregard  of 
the  "world  without."  Sensation,  per- 
ception, volition,  and  emotion,  all  are 
absent.  Through  this  living  death  there 
lingers  in  the  heart  the  only  spark  of 
vitality  that  keeps  the  unconscious 
drunkard  alive,  till  the  faculties  have 
emerged — if,  indeed,  they  do  emerge — 
from  the  depth  of  narcotism  into  which 
they  were  plunged.  The  first,  pleasur- 
able stage,  and  the  second  stage,  less 
pleasant,  may  vary  in  intensity  and  du- 
ration, but  the  third  stage,  that  of 
insensibility,  usually  lasts  from  six  to 
twelve  hours   (Xorman  Kerr). 

In  the  first  stage,  that  of  exhilaration 
or  apparent  stimulation,  there  is  an  in- 
crease of  the  heart-rate,  and  frequently 
a  rise  in  the  blood-pressure.  The 
breathing  is  generally  hastened  and  be- 
comes deeper.  The  skin  is  reddened, 
and  the  surface  temperature  rises 
slightly,  owing  to  the  paralyzing  effect 
of  the  alcohol  on  the  superficial  blood- 
vessels, through  which  an  increased 
amount    of     warm     blood,     therefore. 


courses.  The  pupils  are  of  normal  size 
or  slightly  dilated,  and  the  higher  psy- 
chic processes — those  involving  contin- 
ued attention,  reflection,  judgment,  self- 
control — gradually  fall  in  abeyance. 

The  manifestations  of  the  second 
stage  are  similar  to  those  of  the  first, 
but  more  pronounced  and  wath  the 
added  presence  of  motor  inco-ordina- 
tion,  due  to  the  effects  of  the  drug  on 
the  cerebellar  and  spinal  centers.  A 
subjective  feeling  of  intense  peripheral 
warmth  is  experienced,  the  pulse  is  full 
and  bounding,  and  the  respiration  hur- 
ried and  frequently  irregular.  Inco- 
herence of  speech  and  staggering  gait 
are  the  most  prominent  symptoms  of 
this  stage,  though  the  relative  time  re- 
quired for  the  appearance  of  each  va- 
ries notably  in  diflrerent  individuals, 
some  getting  drunk  first  "in  the  legs," 
others  "in  the  tongue."  Xausea  and 
vomiting  may  also  appear,  and  toward 
the  close  of  the  period  facial  pallor  and 
a  tendency  to  syncope  may  be  present. 

In  some  instances  the  first  and  sec- 
ond stages,  instead  of  showing  the 
individual  in  a  condition  of  general 
excitement,  are  characterized  by  de- 
pression of  spirits,  merging  more  or 
less  insensibly  into  the  ultimate  stage 
of  total  cerebral  inaction.  In  another 
group  of  cases,  on  the  other  hand,  the. 
initial  excitement  is  unusually  pro- 
nounced, the  subject  crying  out  loudly, 
experiencing  illusions,  and  even  com- 
mitting acts  of  violence. 

The  third  stage  of  alcoholic  intoxi- 
cation, that  of  unconsciousness  and 
deepening  coma,  is  characterized  by 
successive  abolition  of  the  functions  of 
various  portions  of  the  central  nervous 
system.  The  spinal  cord  and  cranial 
nerve-centers  becoming  depressed,  mo- 
tion and  sensation  are  progressively 
lost.     The  subiect  cannot  be  awakened 


ALCOHOLISM    (CROTHERS). 


543 


by  shouting-  in  the  ear ;  his  nnisculature, 
inckuHng-  the  sphincters,  is  completely 
relaxed,  and  general  sensibility  is  abol- 
ished. The  pulse  may  be  full  and  ap- 
proximately normal  in  rate,  or  may  be 
feeble  and  slow.  The  breathing  is 
slow,  labored,  and  sometimes  irregular 
— an  indication  of  beginning  paralysis 
of  the  medullary  centers.  It  is  also 
stertorous,  owing  to  relaxation  of  the 
muscles  of  the  soft  palate.  The  skin 
is  now  pale  and  covered  with  cold 
sweat,  though  the  face  is  bloated,  the 
lips  purplish  and  swollen,  and  the  con- 
junctivae markedly  congested.  The  tem- 
perature of  the  body  is  lowered,  the 
rectal  reading  being  invariably  reduced 
by  1,  2,  or  even  4°  F.  (Butler).  The 
pupils  may  be  dilated,  especially  in 
cases  of  severe  intoxication,  and  the 
light-reflex  abolished.  The  knee-jerks 
and  other  reflexes  are  likewise  lost. 

In  cases  terminating  fatally,  death 
takes  place  from  respiratory  arrest 
after  a  period  ranging  from  one-half 
hour  to  fifteen  or  twenty  hours  (Pou- 
chet). 

When  an  unusually  large  amount  of 
alcohol  has  been  taken — true  cases  of 
acute  alcohol  poisoning,  as  distin- 
guished from  those  of  ordinary  "intox- 
ication"— the  stages  of  excitement  are 
apt  to  be  of  very  brief  duration  (es- 
pecially if  the  alcohol  has  been  taken 
on  an  empty  stomach),  the  subject  sink- 
ing promptly  into  coma.  Vomiting, 
swallowing  movements,  piercing  cries, 
and  muscular  contractures  betoken  a 
brief  primary  excitation  of  the  nerve- 
centers,  after  which  depression  quickly 
appears,  indicated  by  respiratory  and 
circulatory  disturbances  and  general 
anesthesia.  Convulsions  and  death 
from  respiratory  paralysis  or  edema  of 
the  lungs  may  finally  result. 

Acute  alcoholic  intoxication  in  some 


instances  brings  forth  phenomena  for- 
eign to  the  conventional  manifestations 
already  described.  Thus,  in  some  cases, 
an  epileptic  attack  is  the  most  prom- 
inent result.  It  may  occur  either  in  an 
individual  already  subject  to  epilepsy, 
in  which  event  the  alcohol  acts  indi- 
rectly, being  merely  an  exciting  cause 
of  the  paroxysm ;  or,  it  may  take  place 
as  a  direct  result  of  the  efl^ects  of  al- 
cohol, in  persons  previously  not  subject 
to  epileptic  seizures,  under  which 
circumstances  the  condition  may  be 
termed  a  true  acute  alcoholic  epilepsy. 
Again,  an  outburst  of  acute  mania  may 
be  the  result  of  alcoholic  intoxication. 
Such  a  result  is  seen  most  frequently 
in  cases  of  incipient  or  fully  developed 
general  paralysis.  Similarly  imbeciles 
and  epileptics  are  particularly  likely  to 
experience  hallucinations  under  the  in- 
fluence of  alcohol,  and  to  commit  acts 
of  violence "  upon  the  impulse  of  the 
moment  (Pouchet).  Finally,  hysterical 
paroxysms  may  also  result  from  the 
consumption  of  alcohol,  even  in  rela- 
tively small  amounts,  and  in  individ- 
uals otherwise  never  hysterical  (Kerr). 
DIFFERENTIAL  DIAGNOSIS. 
— In  the  first  two  stages  of  acute 
alcoholic  intoxication,  those  of  excita- 
tion and  of  motor  inco-ordination,  the 
symptoms  present  are  sometimes  dis- 
tinguishable with  difficulty  from  those 
produced  by  the  ingestion  of  other 
drug  excitants,  such  as  opium,  or  from 
those  of  apoplexy,  unless,  as  is  fre- 
quently the  case,  a  clue  to  the  cause  of 
the  disturbance  is  furnished  by  the  find- 
ing of  alcohol  on  the  premises,  or  a 
history  of  alcoholic  indulgence  can  be 
obtained.  In  the  case  of  apoplexy, 
however,  the  uncertainty  is  not  likely 
to  be  of  long  duration,  the  symptoms 
of  excitation  soon  passing  ofif  entirely, 
or  being  promptly  replaced  by  coma. 


544 


ALCOHOLISM    (CROTHERS). 


A  more  important  and  difficult  dis- 
tinction is  that  to  be  made  between  the 
third  stage  of  intoxication  by  alcohol, 
that  of  sleep  and  insensibility,  and 
comatose  conditions,  such  as  uremia, 
apoplexy,  concussion  of  the  brain  (in 
cases  of  fractured  skull),  acute  opium 
or  chloral  poisoning,  and  diabetic  coma. 
In  police  stations  so-called  "drunks" 
are  often  not  such,  and  a  fatal  result 
may  thus  be  practically  insured.  An 
alcoholic  odor  of  the  breath  is,  of 
course,  characteristic  of  alcoholic 
intoxication,  but  it  is  not  path- 
ognomonic ;  an  individual  uncon- 
scious from  another  cause  may,  per- 
haps, have  taken  or  been  given 
alcohol  in  quantity  insufficient  to  in- 
toxicate. 

Though,  according  to  quite  a  number 
of  observers,  pressure  on  the  supra- 
orbital nerves  in  their  respective 
notches  will  elicit  signs  of  life  in  the 
alcoholic  when  it  would  not  in  other 
states  of  unconsciousness,  the  fact 
remains  that  mistakes  have  been,  and 
are  still,  frequently  made  in  the  dif- 
ferential diagnosis  between  ordinary 
cases  of  "drunkenness"  and  cases  of 
fractured  skull.  It  mav,  indeed,  in 
some  instances!  be  practically  impos- 
sible, even  for  the  medical  expert,  to 
form  a  correct  opinion  as  to  the  caus- 
ative agent  until  time  has  been  given 
for  the  disappearance  of  the  alcoholic 
symptoms. 

To  facilitate  the  recognition  of  the 
morbid  condition  that  may  be  present, 
the  following  chart  is  presented . 

PATHOLOGY.— The  most  prom- 
inent of  the  post-mortem  appearances 
in  fatal  cases  of  acute  alcoholic  poison- 
ing is  cerebral  congestion.  While  no 
noteworthy  destructive  lesions  of  the 
cerebral  substance  proper  may  be 
found,  hemorrhagic  extravasations  may 


quite  frequently  be  discovered  in  the 
meninges  at  the  base  of  the  cerebellum, 
in  the  subarachnoid  space,  or  even  in 
the  lateral  ventricles   (Pouchet). 

Marked  congestion  of  the  lungs  and 
respiratory  passages  is  also  coinmonly 
a  feature.  The  right  heart  cavities  may 
be  found  distended  with  semifluid 
blood.  Tardieu  in  one  case  discovered 
apoplectic  extravasations  of  blood  in 
the  lungs.  The  gastrointestinal  mucous 
membranes  may  also  be  markedly  con- 
gested, though  such  a  condition  is,  of 
course,  in  no  sense  peculiar  to  alcohol 
poisoning.  In  the  case  cited  by  Kerr, 
of  a  man  found  dead  after  a  drinking 
bout,  "the  mucous  membrane  of  the 
stomach  was  so  inflamed  and  angry, 
with  patches  of  a  deeper  hue  extending 
over  the  pyloric  surface  to  the  duode- 
num, and  a  grumous,  slightly  muco- 
purulent exudation  from  bleeding 
points,  that  arsenical  poisoning  was  sus- 
pected." Hepatic  congestion  we  would 
naturally  expect  to,  and  frequently  do, 
find  as  a  post-mortem  evidence  of 
acute  alcohol  poisoning. 

Dana  studied  the  brain-cells  in  10 
cases  of  acute  alcoholism  by  the  Nissl 
method  of  staining  with  methyl  violet: 
(a)  patients  who  died  of  alcoholism 
with  all  the  symptoms  of  meningitis 
showed  congestion  of  the  membranes 
(pia,  arachnoid),  with  some  edema  in 
their  texture;  (b)  microscopic  exam- 
ination rarely  showed  any  migration  of 
leucocytes  or  anything  approaching  en- 
cephalitis; (c)  the  larger  (pyramidal 
and  giant)  nerve-cells  showed  pigmen- 
tation to  an  intense  degree,  the  pigment 
being  diffused  through  the  cell-body; 
(d)  the  cytoplasm  showed  various  de- 
grees of  degeneration  (fatty  and  gran- 
ular) ;  (e)  the  cell-body  generally  was 
shrunken,  and  the  nucleus  partially 
so;  (/)  pericellular  nuclei  had  proHf- 


ALCOHOLISM    (CROTHERS). 
Differential  Diagnosis  of  Acute  Alcoholism. 


545 


Consciousness. 

Temperature. 

Pulse. 
Respiration, 

Pupils. 

Skin. 

Reflexes. 

Convulsions. 

Paralyses. 
Odor. 

Urine. 

Emunctories. 

Special  signs. 


Acute 
Alcoholism. 


Uremic 
Coma. 


Not  absolutely       Completely 
lost;   can  usu-  lost. 
ally  be  aroused 
by  shouting  or 
shaking. 


Often    sub- 
normal. 


Prequen  t; 
later  weak. 


Stertorous. 


Usually  di- 
lated; equal, 
and  react  to 
light. 

Face  flushed. 


Sluggish  or 
abohshed. 


Uncommon, 
except  in  dan- 
gerous cases. 

None. 

Alcoholic  odor 
of  breath. 


Contains  al- 
cohol; other- 
wise not  char- 
acteristic. 

Frequently 
incontinence 
of  urine  and 
feces. 


Variable;  not 
uncommonly 
subnormal. 


Often  Cheyne- 

Stokes. 


Normal 
dilated. 


Waxy  pallor. 


Common. 


Rare. 


Urinous  odor 
sometimes. 


Contains  al- 
bumin, casts, 
and  decreased 
urea. 

Anuria  com- 
mon. 


Edema  of 
face  and  feet; 
albuminuric 
retinitis. 


Apoplexy. 


CONCUS.SION 

OF  THE  Brain. 


Partially   or 
entirely  lost. 


Usually  rises 
above  normal. 


Slow, 
tense. 


full. 


Slow,  sterto- 
rous, and  puff- 
ing. 

Dilated  or 
CO  nt ract  ed  ; 
sometimes  un- 
equal. 

Face  flushed 
or  cyanotic ; 
sometimes 
pale. 

Lost  on  para- 
lyzed side  and 
often  on  sound 
side. 

Usually  only 
at  time  of 
stroke. 

Hemiplegia. 
None. 


Not    charac- 
teristic. 


Deviation  of 
head  and  eyes 
to  side  oppo- 
site that  of 
paralysis. 


Rarely  com- 
pletely lost. 


Subnormal. 


Frequent  and 
weak. 


Slow  and  shal- 
low. 


Usually  di- 
lated ;  equal, 
and  react  to 
light. 

Cold  and  pale. 


Sluggish 
lost. 


Late,  if  any. 


Transient,  if 
any.    , 

None. 


Not   charac- 
teristic. 


Retention  of 
urine;  incon- 
tinence of  fe- 
ces. 

Probably  ev- 
idence of  trau- 
ma to  head. 


Opium 
Poisoning. 


Profound  stu- 


Often     sub- 
normal. 


Slow,  full. 


Very    slow. 


Contracted. 


Face  flushed, 
sometimes  cy- 
anosed. 


Uncommon. 


None, 

Laudanum 
odor  on  breath 
sometimes  no- 
ticeable. 

Not  charac- 
teristic. 


No  involun- 
tary evacua- 
tions. 


Diabetic 
Coma. 


Completely 
lost. 


Subnormal. 


Frequent. 


Long-drawn 
inspiration , 
sighing  expi- 
ration. 

Dilated. 


Sometimes 
cyanosis. 


Lost, 


Rare. 


None. 


Sweet    odor 
of  breath. 


'     Glycosuria, 
acetonuria,  di- 
aceturia. 


erated,  and  were  freely  present  in  the 
pericellular  sacs.  In  cases  where 
death  was  due  to  exhaustion  the 
shrinkage  of  cells  was  marked. 

TREATMENT.  — In  common 
drunkenness,  where  the  pallor  and 
depression  are  not  too  marked,  and 
where  the  respiration  is  active  and 
the  pulse  is  good,  the  patient  may  be 
allowed  to  sleep.  The  elimination 
of  the  poison  occurring  rapidly,  he 
awakes  after  several  hours  with  more 


or  less  headache,  depression,  irrita- 
bility of  the  stomach,  and  tremor  as 
results  of  the  intoxication.  Light  and 
easily  digested  food,  Vichy  and  milk 
as  beverages,  and  a  light  aperient,  if 
required,  will  soon  be  followed  by 
recovery.  Ammonium  carbonate,  1 
dram  (4  Gm.)  in  a  glassful  of  water, 
will'  counteract  depression.  Alcohol 
for  the  latter  purpose  should  never  be 
given. 

In  severe  cases  in  which  there  is 

-35 


546 


ALCOHOLISM    (CROTHERS). 


a-  tendency  to  coma,  with  shallow 
breathing  and  feeble  pulse,  the  prob- 
ability that  a  quantity  of  alcohol  is 
still  present  in  the  stomach  should  be 
borne  in  mind.  The  stomach  should 
be  emptied  by  means  of  the  stomach 
tube  and  washed  out  with  warm 
water.  External  heat  should  be  ap- 
plied, especially  to  the  abdomen  and 
feet,  and  the  patient  placed  in  a  warm 
room.  Depressing  emetics  are  con- 
traindicated,  since  the  depression  is 
already  excessive  and  the  dangerous 
feature.  No  alcohol  should  be  admin- 
istered as  a  stimulant.  Hypodermic 
injections  of  strychnine,  atropine,  or 
digitalis  are  of  great  value  to  restore 
the  equilibrium  of  the  circulation. 

In  acute  alcoholism  attended  by 
excitement  and  perhaps  convulsions, 
especially  in  robust  patients,  free 
emesis  should  be  procured  promptly 
by  giving  %o  grain  (0.006  Gm.)  of 
apomorphine  hydrochloride.  This 
usually  causes  vomiting  in  four  or 
five  minutes,  and  is  then  followed  by 
relaxation  and  sleep.  Digitalis  or 
digitalin  has  also  been  recommended 
in  this  class  of  cases  to  counteract 
the  morbid  effects  of  the  poison  on 
the  heart  and  circulation,  and  thus 
restore  the  patient  to  his  normal  con- 
dition much  sooner.  Hot  (105°  F.) 
rectal  enemata  of  saline  solution  are 
also  valuable  in  these  'Cases  during 
the  acute  attack  to  reduce  the  tox- 
icity of  the  blood,  if  the  enema  is 
retained  long  enough  to  insure  ab- 
sorption. Hypodermoclysis  should  be 
resorted  to  if  the  rectal  injections  do- 
not  prove  satisfactory. 

To  obtain  the  hypnotic  action  of 
apomorphine  hydrochloride  it  should 
be  given  hypodermically.  The  dose 
cannot  be  fixed.  It  is  well  to  begin 
with  %o  grain,  or  less,  and  to  repeat 
this    or   give    a    slightly   larger    dose 


within  a  short  time.  Should  vomit- 
ing occur,  the  drug  should  be  discon- 
tinued for  several  hours.  Doses  re- 
peated in  two  or  three  hours  have 
but  little  beneficial  effect.  The  ad- 
ministration of  apomorphine  should 
not  be  repeated  in  patients  who  are 
weak.  The  hypnotic  action  of  the 
drug  lasts  only  a  few  hours,  and  when 
the  patient  awakes  the  condition  is 
practically  unchanged.  The  best  re- 
sults are  obtain  from  the  drug  when 
it  is  followed  in  two  or  three  hours  by 
some  recognized  hypnotic.  Apomor- 
phine should  always  be  given  in  fresh 
solution.  W.  Coleman  and  J.  M.  Polk 
(Amer.  Med.,  March  8,  1902). 

In  the  acute  stage  of  alcoholism,  a 
very  useful  drug  for  hypodermic  in- 
jection is  apomorphine.  In  the  excite- 
ment of  delirium  tremens  a  small  in- 
jection of  this  drug  will  at  once  produce 
a  calm,  the  patient  will  yawn,  and  is 
fast  asleep  almost  before  he  can  be  got 
to  bed.  This  sleep  is  sometimes  pre- 
ceded by  vomiting.  As  the  patient  is 
liable  to  faint  if  sitting  up,  the  injection 
should  be  given  when  he  is  in  a  recum- 
bent position.  Usually  about  four 
hours'  sleep  is  thus  obtained.  But 
apomorphine  is  no  remedy  for  alcoholic 
craving;  while  a  good  way  of  com- 
mencing treatment,  it  is  only  temporary. 
The  drugs  to  be  relied  on  to  do  away 
with  the  craving  for  alcohol  are 
strychnine  and  atropine;  they  should 
be  kept  in  solution  and  the  injections 
given  into  the  biceps  muscle  twice  or 
three  times  a  day.  Bolton  (Brit.  Med. 
Jour.,  Oct.  12,  1907). 

The  value  of  apomorphine  hydro- 
chloride in  acute  alcoholism  was 
pointed  out  by  C.  J.  Douglas,  of  Bos- 
ton, in  1899,  but  remains  almost  un- 
known. The  drug  acts  promptly 
when  administered  as  an  emetic  in 
doses  of  %o  or  %  grain,  and  it  acts 
with  almost  equal  promptness  when 
administered  as  an  hypnotic.  The 
alcoholic,  however  wild  or  noisy,  will, 
as  a  rule,  be  peacefully  sleeping  in 
ten  or  twelve  minutes  after  %o  to  %o 
grain  is  administered  subcutaneously. 
This  sleep  may  last  several  hours, 
when  the  patient  awakens   refreshed 


ALCOHOLISM    (CROTHERS). 


547 


and  sober.  Douglas  employed  the 
remedy,  with  these  doses,  in  over 
200  cases,  mostly  alcoholics,  including 
cases  of  delirium  tremens,  and  with 
gratifying  results.  Drs.  Coleman  and 
Polk,  of  Bellcvue  Hospital,  New  York, 
used  it  in  over  300  cases  of  alcoholism  ; 
also  with  gratifying  results.  Dr.  Rosen- 
wasser,  inebriatist  to  Newark  Dispen- 
sary, Newark,  N.  J.,  has  also  used 
apomorphine  in  the  same  manner,  and 
for  the  same  purpose,  and  with  equally 
satisfactory  results.  The  dose  admin- 
istered was  from  1-30  to  ^^0  grain.  With 
these  doses,  the  hypnotic  effect  is  se- 
cured in  67  per  cent,  of  the  cases.  Even 
^0  grain,  in  the  author's  experience, 
is  effective  with  some  patients.  A.  M. 
Rosebrugh  (Can.  Jour.  Med.  and  Surg.. 
Oct.,  1908). 

Apomorphine   is    of  great   value   in 
acute  alcoholism.     The  desire  for  liquor 
in    these     cases     becomes     imperatively 
dominant.    Apomorphine  enforces  sleep, 
and  when  the  patient  awakens  his  chain 
of   thought   has    been   broken    and   the 
attack   is   over   in   many  cases.     In   all 
such  cases  the  action  of  an  emetic  is  of 
some  value  in  sobering  the  patient  and 
diminishing  or  abolishing  the  desire  for 
more    drink,    and,    therefore,    the    dose 
usually  given  is  %o  grain  by  hypodermic 
injection,  adding  %o  grain  strychnine 
if  the  heart  is  acting  poorly.     When- 
ever possible  when   given  the  injec- 
tion  the   patient   should   be    hnng  in 
bed,  and   basins    should  be  in   readi- 
ness,   as    the    action    of    the    drug   is 
rapid.     The   author  has   always   been 
able  to  secure  the  hypnotic  effect.    In 
many    cases    %o    grain    given    hypo- 
dermically  will  be  found  sufficient  to 
induce  sleep.    If  the  general  condition 
of  the   patient  is   fair  the   dose   may 
safely    be    repeated    in    about    three 
hours,  if  necessary,  as  the  drug  is  not 
cumulative  in  its  action.    C.  A.  Rosen- 
wasser    (Med.   Times,    Dec,    1910). 

CHRONIC  ALCOHOLISM. 

DEFINITION.— A  condition  re- 
sulting from  the  long-continued  use 
of  alcohol  in  excessive  amounts.  As 
was  stated  to  be  the  case  with  acute 


alcoholism,  the  quantity  of  alcohol 
necessary  to  cause  harmful  results 
varies  considerably  in  different  per- 
sons. The  manifestations  of  chronic 
alcoholism  are  varied.  Many  symp- 
toms due  to  toxemia  and  functional 
derangements  closely  simulating  or- 
ganic changes  are  observed  in  the 
beginning.  Later  evidences  appear 
of  true  organic  disease,  affecting  one 
or  more  organs  or  systems  of  organs 
in  individual  cases.  Thus  the  stom- 
ach, the  nervous  system,  the  circula- 
tory organs,  the  kidneys,  the  liver, 
are  all  common  seats  of  special  inva- 
sion. In  many  cases  the  S3^mptoms 
are  very  complex,  and  are  not  such 
as  lead  to  the  discovery  of  any  par- 
ticular organic  lesion.  As  already 
stated,  the  alcoholism  is  itself  some- 
times secondan,'  to  a  neurosis  of 
other  nature,  in  which  event  complex- 
ity of  symptoms  is  to  be  expected. 

Dipsomania  signifies  a  condition,  he- 
reditary in  origin,  in  which  uncon- 
trollable desire  for  alcohol  is  present 
at  intervals  only,  the  patient  being 
free  of  alcoholic  tendencies  in  the 
intervening  periods. 

Delirium  tremens  is  another  special 
manifestation  arising  from  the  pro- 
longed eft'ects  of  alcohol  on  the  brain. 
It  will  be  discussed  later  in  a  separate 
section  of  this  article. 

SYMPTOMS— Most  cases  will  ex- 
hibit in  the  beginning  deranged  diges- 
tion, fermentation  in  the  stomach  and 
bowels,  constipation  or  diarrhea,  muf- 
fled heart-sounds,  irregular  action  with 
high-tension  pulse,  and  increased  dull- 
ness over  the  liver,  perhaps  with 
tenderness  in  spots.  There  is  very 
commonly  trembling,  the  hands  are  un- 
steady in  their  movements,  the  reflexes 
are  diminished  or  absent,  and  there  are 
areas   of  extreme   tenderness  over  the 


548 


ALCOHOLISM    (CROTHERS). 


body,  while  numbness  of  the  Hnibs, 
rheumatic  pains  in  both  the  lower  and 
upper  extremities,  congested  conjunc- 
tivje  and  retinae,  and  defects  of  both 
sight  and  hearing  are  often  present. 
The  patient  may  complain  of  anorexia, 
insomnia,  chills,  and  frequently  talks 
about  malaria  as  the  cause  of  his  symp- 
toms. The  urine  is  likely  to  be  of  high 
specific  gravity,  and  to  show  albumin 
and  an  excess  of  phosphates.  Chronic 
catarrhal  conditions  of  the  pharynx 
and  larynx,  dilatation  of  the  skin  ves- 
sels, sometimes  pustular  eruptions,  are 
other  early  symptoms  often  seen. 

At  a  later  period  the  symptoms  are 
more  likely  to  point  to  certain  struc- 
tures of  the  body  upon  which  the  alco- 
hol has  exerted  its  chief  effect.  They 
may  be  grouped  as  follows : — 

( 1 )  Digestive  System. — Chronic  gas- 
tritis is  a  very  frequent  result  of 
alcoholism.  The  patient  complains  of 
anorexia,  nausea  and  vomiting,  acute 
pain  over  the  stomach,  and  constipa- 
tion. The  breath  is  foul  and  the  tongue 
coated.  These  symptoms,  usually  most 
marked  in  the  morning,  the  subject 
finds  to  be  best  relieved  by  further  use 
of  alcohol.  The  relief  is  but  temporary, 
however,  and  when  it  ends  the  diffi- 
culty is  increased. 

Long-continued  alcoholic  intoxica- 
tion produces  in  some  cases  pronounced 
structural  changes  in  the  liver,  most 
frequently  cirrhosis,  with  contraction 
of  the  organ,  or  fatty  infiltration,  with 
increased  size.  The  symptoms  of  the 
former  are  those  of  chronic  catarrh  of 
the  stomach  and  intestines  (anorexia, 
nausea,  flatulence,  constipation,  some- 
times light-colored  stools), — which  is 
favored  by  the  congestion  caused  in 
these  organs  through  compression  of 
the  portal  vessels,^ — together  with 
others  directly  due  to  the  same  con- 


dition, such  as  hemorrhages  from 
the  lower  esophagus,  nose,  pharynx, 
or  even  the  stomach  or  intestines; 
hemorrhoids;  distention  of  the  veins 
of  the  face,  especially  the  nose,  or 
of  other  portions  of  the  body,  usually 
combined  with  flushing  due  to  over- 
filled capillaries;  occasionally  jaun- 
dice. Later  there  may  appear  ascites, 
edema  of  the  right  pleura  or  of 
the  lower  extremities.  Enlargement 
of  the  spleen  is  common  late  in  the 
disease.  Fatty  infiltration  of  the  liver 
produces  no  such  distinctive  symptoms, 
since  there  is  no  portal  obstruction. 
The  organ  shows  a  moderate  increase 
in  size,  but  its  functions  are  not  mark- 
edly altered. 

Fahr  reports  a  series  of  309  autopsies 
performed  at  the  Hafenkrankenhaus 
(harbor  hospital)  of  Hamburg  on  vic- 
tims of  chronic  alcoholism  dying  from 
either  alcoholism  alone  or  from  other 
causes,  no  less  than  98  being  suicides. 
In  nearly  all  the  cases  the  alcohol  had 
been  taken  in  the  formi  of  spirits,  not 
as  beer  or  wine.  The  results  of  these 
autopsies  are  distinctly  not  in  harmony 
with  the  conception  that  alcohol  is  a 
poison  which  produces  widespread  and 
gross  anatomic  changes  throughout  the 
body,  or  that  it  is  a  common  cause  of 
either  arteriosclerosis  or  nephritis. 
Even  cirrhosis  of  the  liver  is  far  less 
common  in  alcoholics  tha-  it  is  usually 
supposed  to  be,  for,  of  the  309  cases, 
in  but  11  was  cirrhosis  the  cause  of 
death ;  in  2  other  bodies  there  was  an 
advanced  cirrhosis,  but  death  was  due 
to  some  other  cause.  Of  100  cases  of 
cirrhosis  in  which  autopsies  were  per- 
formed by  Simmonds  in  Hamburg, 
alcoholism  could  be  excluded  in  14;  in 
60  it  was  evident,  and  in  26  there  was 
no  reliable  information  as  to  alcohol ; 
therefore,  it  must  be  concluded  that, 
while  only  a  very  small  proportion  of 
drunkards  suffer  from  cirrhosis  (about 
4  per  cent.),  there  are  not  a  few  cases 
of  advanced  cirrhosis  which  are  not 
due  to  alcoholism,   although  alcohol  is 


ALCOHOLISM    (C  ROT  HERS). 


549 


responsible  for  far  more  than  a  major- 
ity of  all  cases  of  cirrhosis.  On  the 
other  hand,  in  nearly  every  case  of 
habitual  drunkenness  the  liver  shows 
fatty  changes,  usually  severe,  but  not 
ordinarily  associated  with  connective- 
tissue  increase,  and  this  is  by  far  the 
most  frequent  change  in  alcoholism. 
Editorial  (Jour.  Amcr.  Med.  Assoc, 
Nov.  27,  1909). 

(2)  A^crvous  System. — In  many- 
cases  alcohol  acts  most  prominently  as 
a  motor  paralyzer,  the  control  over  the 
muscles  being-  greatly  impaired.  The 
hands  are  unsteady  in  their  movements, 
and  protrusion  of  the  tongue  is  im- 
perfect. Ultimately  paralysis  is  a  pos- 
sibility. 

Of  500  alcoholic  cases  examined, 
a  considerable  number  showed  no 
tremor.  A  moderate  trembling  of  the 
hands  does  not  necessarily  point  to 
an  abuse  of  alcohol.  In  about  one- 
half  of  the  writer's  cases,  a  tremor 
was  noted  which  had  no  relation  to 
the  use  of  alcohol.  A  slight  tremor 
is  more  often  seen  in  total  abstainers 
and  moderate  drinkers  than  in  ex- 
cessive drinkers.  Women  show  a 
greater  tendency  to  tremor  than  men. 
Fiirbringer  (Berl.  klin.  Woch.,  May 
22,  1905). 

In  other  cases  cerebral  symptoms  are 
especially  marked,  the  prolonged  action 
of  the  narcotic  having  caused  a  gradual 
loss  of  mental  power.  Normal  cerebral 
activities  are  replaced  now^  by  exhilara- 
tion, again  by  depression.  The  subject 
becomes  sluggish  mentally,  weak  mor- 
ally, and  loses  in  memory  and  will 
power.  He  may  also  show  great  irrita- 
bility, or  be  in  a  continuous  state  of  ex- 
citement. His  ideals  are  changed,  and 
egotistic  tendencies  appear.  Later,  evi- 
dences of  abnormal  cerebration  may  oc- 
cur in  the  form  of  varying  delusions  and 
delirium.  Permanent  dementia  is  the 
terminal  stage  in  this  morbid  chain  of 
events,  the  patient  becoming  in  his  de- 


lusions timorous,  suspicious,  and  some- 
times grandiose.  The  symptoms  of 
simple  or  multiple  neuritis  are  also 
very  frequently  seen  in  cases  of  alco- 
holism, occasionally  to  the  extent  of 
permanent  local  paralysis  (see  Alco- 
holic Neuritis  under  Neuritis). 

If  carefully  sought  for,  various  forms 
of  insanity  following  the  use  of  alco- 
hol can  easily  be  distinguished  from 
the  ordinary  intoxications.  In  favor  of 
insanity  are:  A  neurotic  family  taint; 
slight  changes  in  character  and  dis- 
position, especially  moral  and  ethical 
changes;  periodicity  of  the  drink  habit, 
weakening  of  the  memory  and  of  the 
will,  a  tendency  to  excessive  anger,  and 
periods  of  depression.  A  point  of  great 
significance,  the  writer  believes,  is  the 
fact  that  occasionally,  after  the  with- 
drawal .of  the  whisky,  there  will  a;)- 
pear  periodically  a  condition  closely 
resembling  that  of  intoxication.  This 
he  regards  as  a  sure  sign  of  mental 
change,  which  should  be  treated  by  re- 
straint o"f  the  patient  for  a  long  period. 
The  author  makes  a  strong  plea  for 
State  provision  for  the  cure  of  dip- 
somania. Dunning  (St.  Paul  Med. 
Jour.,  Sept.,  1903). 

Alcoholic  insanity  presents  special 
characteristic  features  which  it  is  not 
difficult,  in  the  majority  of  cases,  to 
distinguish  from  other  analogous  con- 
ditions. Acute  cerebral  alcoholism  pre- 
sents 3  states :  delirious,  confusional, 
and  stuporous.  The  intensity  of  these 
states  varies  according  to  whether  we 
deal  with  a  subacute  form  or  with 
delirium  tremens. 

The  chronic  form  leads  inevitably  to 
dementia.  In  the  course  of  develop- 
ment of  the  latter,  delusions  with 
hallucinations  and  illusions  may  and 
may  not  manifest  themselves. 

In  the  latter  symptoms  it  may  some- 
times present  a  picture  of  any  other 
psychosis ;  this  resemblance  is  only  ap- 
parent, as  in  the  majority  of  cases  close 
observation  will  enable  us  to  find  the 
proper  interpretations. 

If  the  symptoms  characteristic  of 
cerebral     alcoholism    sometimes     de- 


550 


ALCOHOLISM    (CROTHERS). 


velop  in  individuals  affected  with 
other  psychoses  who  happen  to  com- 
mit excesses,  or  do  so  because  of  the 
perverted  mode  of  thinking-  or  feeling 
caused  by  the  psychoses,  it  does  not 
follow  that  alcohol  is  capable  of 
producing  these  psychoses.  The  con- 
ception of  alcoholic  melancholia, 
mania,  paranoia,  or  paresis  is  un- 
scientific. Alfred  Gordon  (Jour,  of 
Inebriety,  AA'inter,   1908-9). 

(3)  Circulatory  System.  —  Alcohol 
causes  irritation  of  the  intima  of  the 
vessels  and  gradual  degeneration  of  the 
vascular  walls.  The  symptoms  pro- 
duced are  those  usual  in  widespread 
arteriosclerosis:  vertigo,  hemorrhage 
or  throm.bosis  of  the  cerebral  vessels, 
etc.  The  heart  and  kidneys  are  very 
likely  to  be  involved  as  a  result  of  the 
same  changes  and  undergo  correspond- 
ing alterations  in  function. 

In  some  instances  the  heart  seems 
seriously  affected.  The  patient  com- 
plains of  distress  and  pain  over  the 
precordial  region,  with  alternate  feel- 
ings of  exhaustion  and  exhilaration. 
The  pulse  is  frequent,  and  surface  con- 
gestion is  very  intense.  The  heart  may 
become  dilated. 

(4)  Kidneys. — Chronic  parenchyma- 
tous nephritis  is  not  uncommonly 
caused  by  prolonged  alcoholic  excesses. 
Its  manifestations  include  disorders  of 
digestion,  increased  vascular  tension, 
anemia  with  characteristic  translucent 
pallor,  tendency  to  swollen  face  and 
extremities,  together  with  more  or  less 
distinctive  changes  in  the  urine.  The 
latter  consist  of  abnormalities  in  quan- 
tity (at  first  diminished,  later  in- 
creased), lower  specific  gravity,  albu- 
minuria; granular  casts,  sometimes 
fatty;  epithelial  and  waxy  casts,  and 
decreased  proportion  of  urea.  The  late 
symptoms  include  marked  weakness, 
general  anasarca,  dyspnea  on  exertion, 
and  uremia, 


From  a  clinical  study  of  460  cases  of 
chronic  alcoholism  the  writer  concludes 
that  alcohol  when  taken  daily,  as  it  is 
by  chronic  inebriates,  dipsomaniacs,  or 
drinkers,  is  not  an  irritant  to  the  kid- 
neys. \A'hen  nephritis  occurs  in  a 
chronic  alcoholic,  it  is  probably  due  to 
some  other  concomitant  toxic  agent, 
and  not  to  alcohol.  Overeating,  acute 
intoxicants,  exposure  to  colds,  auto- 
intoxications, infections  either  mani- 
fest or  latent,  and  some  metabolic  dis- 
orders as  jet  unknown  are  the  real 
causative  factors  of  nephritis. 

Alcohol  when  taken  by  drinkers  as 
food  or.  stimulant,  such  as  seen  in 
chronic  alcoholism,  is  a  diuretic.  Those 
tissues  which  eliminate  alcohol  are  least 
affected  by  it.  This  applies  to  the  lungs 
and  especially  to  the  kidneys.  While 
an  intoxicant,  alcohol  is  also  a  de- 
toxicant,  ridding  the  body  of  various 
deleterious   catabolic  products. 

The  comparative  integrity  of  the  kid- 
neys in  alcoholics  may  be  due  to  the 
fact  that  the  renal  cells  contain  very 
few  lipoids  and  lecithins,  and  that, 
therefore,  they  are  not  at  all  acted  on 
by  the  narcotic  molecule.  J.  F.  Hult- 
gen  (Jour.  Amer.  Med.  Assoc,  July  23, 
1910). 

DIAGNOSIS.  — This  is  facilitated 
if  a  history  of  excessive  use  of  alcohol 
— at  times  in  the  form  of  proprietary 
remedies — be  obtainable.  If  not,  alco- 
holism is  suggested  by  the  presence  of 
symptoms  such  as  those  given  in  the 
beginning  of  the  section  on  symptoms, 
these  representing  mainly  functional 
derangements  and  toxic  effects,  but 
few  of  them  being  the  results  of  organic 
alterations.  Active  treatment  is  then 
begun.  Under  rest,  restricted  diet,  and 
hydrotherapeutic  measures  many  of 
these  symptoms  disappear,  leaving  only 
those  expressive  of  permanent  lesions. 

Quinquaud's  sign  consists  in  a  series 
of  quick  tappings  or  the  sensation  of 
slight  shocks  made  by  the  phalanges 
when  the  patient's  fingers  are  spread 
apart  and  extended  and  pressed  perpen- 


ALCOHOLISM    (CROTIIERS). 


551 


dicularly  against  the  palm  of  the  ex- 
perimenter. It  is  only  after  a  few 
seconds  that  the  phalangeal  shock  is 
felt,  and  then  only  in  case  the  subject 
is  an  alcoholic.  Maridort  (La  med. 
moderne,  July  18,  1900). 

The  writer  has  investigated  Quin- 
quaud's  symptom  in  a  large  number  of 
cases  and  concludes  that  the  crepita- 
tion does  not  come  from  the  joints,  but 
results  from  slight  lateral  motions  of 
the  tendons  in  their  sheaths,  set  up  by 
the  involuntary  muscular  contractions 
so  common  in  alcoholics.  The  symptom 
is  present  to  a  slight  extent  also  in  nor- 
mal individuals.  M.  Herz  (Miinch. 
med.  Woch.,  May  30,  1905). 

Of  14  total  abstainers,  ranging  in 
age  from  22  to  35,  10,  or  71.3  per 
cent.,  showed  Quinquaud's  phenom- 
enon, which  was  well  marked  in  50 
per  cent.  In  a  group  of  25  moderate 
drinkers  the  phenomenon  was  present 
in  14,  or  56  per  cent.;  very  marked  in 
28  per  cent.  Minor  (Berl.  klin. 
Woch.,  May  6,  1907). 

A  careful  re-examination  at  the  end 
of  two  or  more  weeks  will  now  indicate 
how  many  of  the  symptoms  were  func- 
tional, and  which  of  them  seemingly 
Avere  organic  departures  from  health. 
The  special  effects  of  the  alcohol  on 
particular  organs  or  systems  of  the 
body  are  ascertained  by  noting  the 
presence  of  symptoms  referable  to 
them,  such  as  have  already  been  men- 
tioned under  that  heading.  It  must  be 
admitted,  however,  that  in  many  cases 
the  symptoms  will  appear  very  com- 
plex and  refer  to  no  particular  seat  of 
organic  disease. 

At  this  second  examination  the  diag- 
nosis of  the  patient's  psychic  state  can 
also  be  made  with  some  accuracy.  This 
should  comprise  a  study  of  the  pa- 
tient's powers  of  reasoning,  of  his 
ideals,  of  his  ethical  conceptions  of 
life,  of  the  end  and  object  in  living,  of 
his  purposes  and  ambitions,  of  the  ef- 
fects of  losses  and  mental  strains  on 


his  character,  of  the  dominance  of  cer- 
tain passions  and  unrestrained  emo- 
tional activities,  and  of  the  presence  of 
morbid  impulses  and  egotism.  The 
inquiry  should  extend  to  the  every- 
day habits  of  the  patient.  Not  infre- 
quently periods  of  unexplained  absence 
from  home  and  business,  and  of  unex- 
pected and  obscure  conduct,  will  be 
revealed.  Such  occurrences  justify  the 
inference  of  the  paroxysmal  use  of  al- 
cohol. Often  the  pronounced  convic- 
tions of  the  patient  as  to  the  cause  of 
his  condition  are  significant  of  the  use 
of  spirits,  which  he  denies.  The  diag- 
nosis can  then  be  made  with  great 
clearness  not  from  what  he  says,  but 
from  the  fact*  he  conceals  or  appears 
to  be  trying  to  cover  up. 

Material    assistance    will    sometimes 
be  derived  from  a  study  of  the  family 
history  and  past  medical  history.     He- 
reditary   tendencies,    the    diseases    of 
childhood,    profoundly    exhausting    fe- 
vers, and  injuries  to  the  body  may  all 
be  of  importance  in  reaching  a  decision. 
The  heredity  element  in   inebriety  is 
considerable     and     is     undoubtedly     a 
powerful     predisposing     cause     in     in- 
ebriety.     A   history   of    decided    intem- 
perance in  the  parents  existed  in  over 
40  per  cent,   of  the  writer's  700  cases, 
while    15   per    cent,    gave    a    history    of 
defective  ancestry,  insanity,  neuropathy, 
drug    addiction    or    tuberculosis    being 
present    on    the    maternal    or    paternal 
side.     Approximately  5  per  cent,  of  the 
patients     showed     pre-existent     mental 
symptoms  which  could  be  differentiated. 
Some   of   these   were    distinct   cases   of 
psychasthenia ,      others     were     of     the 
milder    forms    of    mani'c-depressive    in- 
sanity.    Neff    (Boston  Med.  and  Surg. 
Jour.,  June  16,  1910). 

The  influences  and  conditions  sur- 
rounding the  subject  at  the  period  of 
puberty,  the  effects  on  him  of  losses 
and  failures  early  in  life  should  likewise 
be  ascertained,  since  they  may  have  a 


552 


ALCOHOLISM    (CROTHERS). 


marked  bearing  on  the  establishment 
of  vicious  habits.  If  alcohol  has  been 
taken,  no  matter  how  moderately  at 
first  or  at  what  long  intervals,  its  in- 
fluence upon  subsequent  morbid  devel- 
opments should  be  given  due  consider- 
ation. 

Where  the  symptoms  are  complex 
and  the  diagnosis  obscure,  it  is  usually 
safe  to  give  prominence  to  alcohol  as 
a  causative  factor.  In  many  such  cases 
alcohol  is  used  to  conceal  the  taking  of 
other  drugs.  The  diagnosis  can  then 
only  be  a  tentative  one,  the  strong 
probability  of  an  alcoholic  neurosis  be- 
ing, however,  kept  in  mind.  It  may 
have  to  be  altered  at  any  time  upon  the 
discovery  of  new  facts  in  the  patient's 
history  or  in  his  present  condition. 

PATHOLOGY.  — In  this  are  in- 
cluded changes  in  a  large  number  of 
organs  and  tissues.  It  has  been 
shown,  indeed,  that  alcohol  has  de- 
structive effects  on  protoplasm  in 
general.  Hence,  cellular  elements 
of  all  kinds  are  open  to  its  action, 
though  it  has  been  recognized  that 
it  is  the  most  highly  differentiated 
cells,  such  as  those  of  the  nervous  sys- 
tem, which  are  the  most  easily  affected. 
Its  influence  on  the  cells  is  exerted  by 
reduced  oxidation  and  altered  metabo- 
lism. Destroyed  cells,  in  virtue  of  a 
low-grade  inflammatory  process  it 
produces,  are  replaced  by  connective 
tissue.  The- effect  of  alcohol  in  dimin- 
ishing oxidation  is  most  prominently 
expressed  in  the  failure  to  oxidize  fats 
normally,  with  consequent  accumula- 
tion, as  in  the  liver  and  subcutaneous 
tissues. 

Distinction  made  between  the  diffuse, 
irregular  spinal  cord  changes  brought 
about  by  alcohol  and  the  more  system- 
atized processes.  The  diffuse  changes 
consist  in  a  thickening  of  the  vessel 
walls    and    increase    in    the    connective 


tissue  of  the  pia  and  of  the  cellular 
tissue  surrounding  the  cord,  hyaline 
degeneration  of  the  small  vessels,  and 
a  diffuse  gliosis,  which  destroys  the 
nerve-fibers.  The  changes  are  not 
different  from  those  found  in  arterial 
sclerosis  and  marasmus.  Commonly 
the  changes  are  most  marked  in  the 
posterior  portions  of  the  cord.  The 
more  symmetrical  changes  are  found  in 
the  posterior  column,  with  projections 
into  the  posterior  roots,  especially 
marked  in  the  lumbar  enlargement. 
This  was  frequently  associated  with 
changes  in  the  peripheral  nerves.  The 
changes  could  not  be  distinguished 
from  those  of  beginning  tabes.  E.  A. 
Homen  (Zeit.  f.  klin.  Med.,  Bd.  xlix, 
H.   1-4,  1903). 

PROGNOSIS.  — This  is  generally 
very  favorable.  Statistical  studies  in 
well-conducted  institutions  show  that 
at  least  one-third  of  all  the  cases 
are  permanently  restored.  The  state- 
ments that  90  per  cent,  are  cured  have 
reference  to  present  conditions,  and 
are  probably  true  for  a  limited  time. 
On  the  turn  of  the  drink  cycle  relapse 
occurs,  and  later  recovery. 

Statistics  of  cure  are  unreliable.  In 
the  treatment  by  gold  chloride  95  per 
cent,  were  claimed  to  be  cured.  At  the 
end  of  one  year  after  treatment  55  per 
cent,  had  relapsed.  At  the  end  of  the 
second  year  another  20  per  cent,  began 
to  drink  again.  In  the  third  only  10 
per  cent,  continued  temperate  and  free 
from  spirits.  On  the  other  hand,  at 
Binghamton,  N.  Y.,  where  the  first 
exhaustive  study  was  made  of  the  sub- 
sequent history  of  1100  patients,  ten 
years  after  they  had  been  treated,  the 
results  showed  61  per  cent,  still  temper- 
ate and  well.  These  and  other  statistics, 
while  open  to  error,  clearly  suggest 
that  at  least  SSy^  per  cent,  may  be  rea- 
sonably considered  permanently  re- 
stored. 

The  future  of  the  inebriate  depends 


ALCOHOLISM    (CROTHERS). 


553 


largely  on  the  removal  of  the  exciting 
causes,  whatever  they  may  he,  and  their 
avoidance  in  the  future.  In  a  certain 
numher  of  cases  there  is  a  complete 
cessation  and  physiological  change  in 
the  organism  in  which  the  impulse  to 
use  spirits  passes  away  forever.  This 
is  now'  well  known.  It  cannot  be  pre- 
dicted, but  it  occurs  so  often  that  we 
cannot  but  credit  the  results  to  greater 
knowdedge,  and  to  the  use  of  more  ex- 
act means  in  the  treatment. 

It  may  be  stated  that  the  prognosis 
is  always  good,  even  in  cases  that  have 
apparently  reached  the  terminal  stage. 
This  prediction  refers  specifically  to  the 
craze  for  alcohol.  This  dies  out,  is 
overcome  by  drugs  and  rational  treat- 
ment, while  other  conditions  of  degen- 
eration may  remain. 

The  alcoholic  or  inebriate  is  a  com- 
pound of  a  great  variety  of  causes,  the 
removal  of  which  brings  about  cure. 
Sometimes  those  causes  are  very  insig- 
nificant, sufficiently  so,  in  fact,  to  be 
readily  overlooked. 

TREATMENT.  — This  resembles 
the  prognosis  in  uncertainty  and  wdde 
variations,  indicating  beyond  ques- 
tion that  the  subject  has  been  scarcely 
touched.  Both  hospital  and  home 
treatment,  and  even  moral  measures, 
show  examples  of  permanent  restora- 
tion. The  field  is  very  wide  and 
largely  unknowm. 

Home  Treatment, — First,  there  is 
the  home  treatment,  i.e.,  care  given  to 
the  patient  in  his  own  home  by  the 
family  physician.  It  is  evidently  pos- 
sible to  restore  many  persons,  partic- 
ularly if  they  give  their  full  assent  and 
co-operation  and  carry  out  the  meas- 
ures laid  down  for  them. 

Home  treatment  requires  implicit 
confidence  in  the  medical  adviser,  and 
should  consist  of  the  absolute  with- 


drawal of  spirits  and  the  use  of 
means  and  measures  to  restore  and 
relieve  the  conditions  of  starvation 
and  poisoning  present. 

While  the  causes  difi:'er  in  each  case, 
their  removal  and  the  after-treatment 
are  substantially  the  same.  Thus,  one 
whose  living,  both  in  regard  to  nutri- 
tion and  rest,  is  bad  nequires  a  change. 
Nerve  rest  and  regular  diet  must  be  a 
part  of  the  treatment. 

In  one  who  has  become  poisoned 
by  spirits  and  highly  stimulating 
foods,  the  withdrawal  of  these  agents 
and  rest  are  essential.  Probably  hy- 
dropathic measures  to  insure  elimina- 
tion by  means  of  the  skin  represent 
the  most  efifective  method  of  treat- 
ment. 

Many  of  these  patients  are  sufifering 
from  delusional  egotism  and  inability 
to  recognize  their  condition  (con- 
stantly overrating  their  strength), 
and  are  unwilling  to  use  the  means 
so  evident  to  others.  The  family 
physician  should  be  dogmatic  and  ex- 
act the  use  of  means  and  measures 
that  will  break  up  the  impulse  to 
use  spirits.  He  should  treat  the  pa- 
tient mentally  as  well  as  physically, 
and  the  danger  of  the  situation  should 
never  be  minimized;  he  should  not 
permit  the  patient  to  think  that  he 
can  depend  on  his  own  will  to  over- 
come his  diseased  impulses.  In  many 
instances  the  patient  is  impressed  with 
the  gravity  of  his  disorder.  He  must 
be  urged  to  make  radical  changes  in 
his  living  and  conduct.  If  his  work 
is  indoors,  a  change  to  out-of-door 
life  is  requisite.  If  he  has  neglected 
proper  exercise,  this  should  be  ar- 
ranged for  in  some  satisfactory  way. 

Everything  that  will  change  the  pres- 
ent current  of  thought  wath  mental  and 
physical    activity    belongs    to    rational 


554 


ALCOHOLISM    (CROTHERS). 


treatment.  Of  course,  with  this,  ap- 
propriate remedies  and  measures  to 
neutraHze  and  diminish  exciting  causes 
Avill  suggest  themselves  to  the  physi- 
cian. He  should  recognize  that  these 
are  often  border-line  cases  in  which 
both  reason  and  will  are  clouded  and 
the  patients  are  irresponsible.  They 
need  suggestion,  forcible  and  em- 
phatic; physical  treatment,  and  per- 
sistent use  of  all  therapeutic  means. 
The  family  physician  can  do  a  great 
deal  in  this  field  if  he  will  prepare 
himself  for  it  and  study  the  peculiar- 
ities of  the  patient. 

Office  Treatment. — This  is  equally 
promising  in  results  where  the  patient 
is  recognized  by  the  physician  and 
his  condition  understood.  Drug 
treatment  forms  a  very  important 
part  of  the  means  to  bring  relief. 
Probably  the  most  practical  drugs 
are  combinations  of  strychnine  and 
atropine,  given  at  short  intervals  for 
a  few  weeks,  then  replaced  by  some 
other  agent. 

Strychnine  is  the  physiological  an- 
tagonist of  alcohol,  and  when  properly 
administered  it  will  remove  the  appe- 
tite for  alcohol.  It  will  do  this  without 
detriment  to  the  system  in  any  respect, 
and  usually  with  the  greatest  benefit. 
Other  remedies  may  with  advantage  be 
combined  or  alternated  with  strychnine, 
especially  atropine  or  hyo scy amine ; 
but  it  is  strychnine  which  does  the 
lion's  share  of  the  work,  and  it  can 
usually  be  done  with  strychnine  alone. 
J.  M.  French  (Merck's  Archives, 
April,  1907). 

Favorable  report  of  treatment,  essen- 
tially that  first  proposed  by  McBride, 
which  consists  in  the  hypodermic  in- 
jection of  atropine  and  strychnine 
twice  or  thrice  daily  for  a  month  or 
six  weeks,  with  attention  to  general 
hygienic  condition,  and  tonics  by  the 
mouth.  At  the  commencement  of  the 
treatment  patients  were  told  that  its 
success   depended   on  their   regular   at- 


tendance for  injections.  The  writer 
reports  7  cases,  all  of  them  presenting 
marked  degrees  of  alcoholism,  which 
had  been  treated  in  this  way.  In  5, 
treatment  was  commenced  in  Septem- 
ber, 1905;  July,  1907;  March,  1908  (2 
cases),  and  July,  1909,  respectively. 
These  cases  had  remained  cured  up  to 
date.  In  the  2  other  cases  relapses  had 
occurred  after  two  months  and  four 
years  respectively.  W.  Asten  (Lancet, 
Nov.  6,  1909). 

The  impulse  to  drink  may  be  effect- 
ually controlled  by  small  doses  of 
apomorphine  given  hypodermically  or 
by  the  mouth.  Concentrated  aqueous 
infusion  of  quassia  given  every  hour 
very  quickly  breaks  up  the  drink  im- 
pulse, and  frequently  destroys  the 
taste  for  tobacco,  which  is  often  a 
very  important  factor  in  the  use  of 
spirits. 

In  the  office  treatment  care  should 
be  exercised  not  to  substitute  for 
spirits  narcotic  drugs  that  are  likely 
to  produce  poisonous  effects  if  taken 
without  caution.  Chloral  hydrate  is 
one  of  these  drugs,  commonly  admin- 
istered, but  it  is  unsafe  and  dangerous ; 
also  many  forms  of  opium  and  its  de- 
rivatives. 

Humulus  is  a  narcotic  of  great 
power  at  times,  and  is  often  an  excel- 
lent substitute  for  spirits.  It  is  not 
wise  to  give  tinctures  to  patients  who 
come  to  the  office  for  treatment.  Give 
infusions  always.  Salines  are  very 
practical  measures  and  can  be  given 
freely  without  risk. 

Office  patients  of  this  class  want 
remedies  that  will  impress  them  at 
once ;  hence,  the  physician  must  study 
the  drugs  whose  effects  are  more  or 
less  certain.  Sodium  bromide  is  a 
favorite  drug,  and  can  be  used  with 
safety;  only,  the  physician  must 
realize  that  it  is  cumulative  in  its  ac- 
tion,  and   that  baths,  cathartics,   and 


ALCOHOLISM    (CROTHERS). 


SS5 


diuretics  are  to  be  associated  with  its 
use  constantly. 

Office  patients  should  be  urged  to 
take  daily  baths  and  exercise  in  the 
open  air,  but  should  be  impressed 
psychically  with  the  need  of  avoiding 
causes  which  lead  or  predispose  to 
exhaustion.  It  is  impossible  to  spec- 
ify particular  drugs  and  a  plan  of 
treatment  applicable  to  every  case. 

The  conditions  vary  so  widely  and 
the  active  and  exciting  causes  de- 
pend on  so  many  circumstances — sur- 
roundings, occupation,  success  or 
failure  in  life,  diet  and  social  influ- 
ences, rest,  etc. — that  each  case  be- 
comes a  law  unto  itself,  and  requires 
a  very  close  study  of  the  conditions 
present. 

Hospital  Treatment. — This  is  far 
more  successful,  particularly  in  per- 
sons who  have  reached  the  later  stages 
of  degeneration.  It  is  a  common  ex- 
perience to  have  persons  go  to  a  hos- 
pital or  sanatorium  and  recover  from 
the  immediate  effects  of  spirits,  and 
have  a  period  of  rest,  change,  and  thor- 
ough elimination  of  the  active  exciting 
causes.  They  can  then  return  to  the 
family  physician  and  remain  under  his 
care  for  an  indefinite  period.  It  often 
happens  that  hospital  treatment  and  re- 
straint is  the  only  measure  that  has 
any  promise  of  permanency.  Such 
hospital  treatment  is  effectual  by 
combining  hydrotherapeutics  and 
sanitary  appliances  with  hygienic 
measures  specifically  adapted  to  meet 
the  wants  of  every  person. 

Drugs  are  very  essential  adjuncts 
and  aid  materially  in  restoring  the 
vigor  and  metabolism  of  the  body. 
Diet  and  exercise  are  also  very  im- 
portant remedies.  These,  with  nerve 
rest,  change  of  thought  and  surround- 
ings,   are    followed    by    restoration, 


and  where  these  measures  are  con- 
tinued over  a  certain  length  of  time 
the  cure  is  permanent. 

The  actively  working  inebriates 
and  alcoholics  who  are  carrying  loads 
of  responsibility  need  hospital-homes 
in  the  country  or  by  the  seashore 
where  absolute  rest  and  quietness  can 
displace  their  usual  unhygienic  ac- 
tivities. The  diet,  exercise,  baths, 
electricity,  tonic  drugs,  new  duties, 
and  new  conceptions  of  their  actual 
conditions  must  be  forced  upon  them 
and  become  a  part  of  their  everyday 
life. 

Here  psychic  therapeutics  comes 
in  as  a  very  important  means  of  treat- 
ment; and  as  a  supplement  to  other 
and  physical  remedies.  A  sanatorium 
hospital  will  supply  these  needs,  af- 
ford a  clear  knowledge  of  the  pa- 
tient's condition,  and  train  him  in  the 
conduct  he  should  observe  in  the 
future. 

The  writer  divides  inebriates  into  2 
classes,  those  whose  will  power  is  not 
destroyed,  but  only  latent  as  it  were, 
and  capable  of  being  revived,  and  those 
in  whom  it  is  hopelessly  impaired.  It 
is  the  first  of  these  classes  that  fur- 
nishes the  converts  in  the  temperance 
revivals  and  the  so-called  successes  of 
the  various  specifics  or  "cures"  for  al- 
coholism, and  the  good  result  here  is 
not  due  to  the  medication,  which  acts 
indirectly  perhaps  as  an  aid  to  mental 
suggestion,  but  to  the  psychic  stimulus 
and  the  environment.  The  conductors 
of  the  so-called  "cures"  are  illogical 
in  their  use  of  remedies  and,  therefore, 
untrue  in  their  assertion  Their  prac- 
tice is  irrational  and  unethical,  and  they 
are  in  no  sense  humanitarian.  They 
should  not  have  the  protection  afforded 
regular  medicine,  but  should  be  brought 
under  the  laws  regulating  "patent"  or 
proprietary  medicines.  There  is  no 
specific  in  the  treatment  of  alcoholism 
or  inebriety  in  the  proper  sense  of  the 
word.     In   a   certain   class   of   selected 


S56 


ALCOHOLISM    (CROTHERS). 


cases  it  is  proper  to  use  psychic  treat- 
ment, especially  before  complications 
develop  and  while  the  patient  is  still 
responsive.  If  the  case  is  complicated 
with  organic  disease  appropriate  medi- 
cal treatment  should  precede  or  accom- 
pany psychotherapeutic  measures  if  the 
latter  are  deemed  advisable.  L.  D. 
Mason  (Jour.  Amer.  Med.  Assoc,  Feb. 
23,   1907). 

There  are  many  hospitals  and  sana- 
toria with  varied  meastires  of  treat- 
ment, but  in  none  of  those  worthy  of 
confidence  are  there  any  specifics  en- 
veloped with  mystery.  The  treatment 
has  passed  beyond  the  empiric  stage, 
and  is  now  as  thoroughly  fixed  with  its 
positive  results  as  that  of  any  other 
disease,  and  there  are  no  specifics 
or  combinations  of  drugs  that  can 
efl^ectually  check  the  drink  impulse 
unless  at  the  peril  of  its  breaking  out 
again  with  greater  force. 

[A  second  class  of  hospitals  should  be 
organized  on  the  workhouse  plan,  providing 
all  the  means  and  measures  found  best  in  the 
sanatorium  with  the  addition  of  making 
labor  a  part  of  treatment.  These  would  re- 
ceive the  indigent  and  the  terminal  cases, 
which  would  be  sent  there  by  process  of  law, 
and  which  would  become  more  or  less  per- 
manent residents.     T.  D.  Crothers.] 

GENERAL  TREATMENT.— Ev- 
ery inebriate  is  toxemic^  and  every 
attack  of  drunkenness  is  a  period  of 
exacerbation  of  this  toxemia.  The 
first  measure  is  to  withdraw  the  spir- 
its and  remove  the  poison  by  stim- 
ulating the  bowels  and  the  skin  to 
insure  its  elimination.  Calomel,  either 
in  a  large  dose  of  10  grains  or  a  small 
dose  of  1  grain  every  two  hours,  until 
6  or  8  grains  are  taken,  together 
with  salines,  are  the  most  efi^ective 
cathartics,  and  should  always  be  used 
at  the  beginning. 

If  the  patient  objects  to  the  sudden 
removal  of  alcohol,  and  his  condition; 


borders  on  delirium,  %o  of  a  grain  of 
apomorphine  hypodermically  should 
be  given  as  a  relaxant.  This  will  be 
followed  by  vomiting,  free  perspira- 
tion, and  sleep.  On  awakening  a  hot 
bath  of  the  temperature  of  105°  or 
110°  should  be  given.  If  the  patient  will 
consent  to  lie  in  the  bathtub  for  an 
hour  or  two  at  a  time,  then  be  rubbed 
'down  and  recline  in  a  cool  room,  ex- 
cellent effects  will  be  obtained.  If 
he  will  not,  an  ordinary  hot  bath 
should  be  followed  by  a  vigorous 
hand  rubbing  and  reclining  in  bed.  If 
the  desire  for  spirits  continues  and 
the  depression  is  not  marked,  %o 
grain  of  strychnine  with  %oo  o^  atro- 
pine should  be  given  every  two  hours. 

To  get  a  man  on  his  feet  with  a  clear 
brain,  and  with  the  craving  for  nar- 
cotics removed,  a  mixture  of  drugs 
given  to  the  writer  by  Mr.  Charles  B. 
Towns  has  proven  of  value.  It  con- 
sists of  a  mixture  of  15  per  cent,  tinc- 
ture of  belladonna,  2  parts,  and  1  part 
each  of  fluidextract  of  xanthoxylum 
and  fluidextract  of  hyoscyamus. 

From  6  to  8  drops  of  this  are  given 
every  hour,  day  and  night,  until  either 
the  patient  shows  symptoms  of  bella- 
donna excess  or,  with  the  cathartics 
about  to  be  described,  the  patient  has  a 
certain  characteristic  stool.  This  dose 
of  the  mixture  is  increased  by  2  drops 
every  six  hours,  until  14  to  16  drops 
are  being  taken ;  it  is  not  increased 
above  16  drops.  Usually  an  alcoholic 
can  be  given  4  compound  cathartic 
pills  (U.  S.  P.)  at  the  same  time 
that  the  specific  is  begun.  After  the 
mixture  has  been  given  for  fourteen 
hours,  a  further  dose  of  C.  C.  pills  is 
given,  either  2  or  4,  depending  upon  the 
amount  of  action  obtained  through  the 
use  of  the  previous  dose.  If  these  have 
acted  very  abundantly,  only  2  are  now 
necessary.  At  the  twentieth  hour  of 
the  mixture  2  to  4  more  C.  C.  pills  are 
given,  and  after  these  have  acted, 
should  the  patient  begin  to  show  abun- 
dant   green    movements,    an    ounce    of 


ALCOHOLISM    (CROTIIERS). 


557 


castor  oil  should  be  given,  and  a  few 
hours  later  the  characteristic  thick, 
green,  mucous,  putty-like  stool  will  ap- 
pear. Usually  the  mixture  has  to  be 
continued,  and  at  the  thirty-second  hour 
2  to  4  C.  C.  pills  are  again  given,  and 
a  few  hours  later  the  castor  oil.  The 
mixture  can  then  be  discontinued. 

Of  course,  in  treating  alcoholics,  one 
finds  in  the  majority  of  cases  the  neces- 
sity to  stimulate  them  and  to  give  them 
some  hypnotic,  but  this  can  be  done 
without  interfering  with  the  hourly  ad- 
ministration of  the  above.  Alexander 
Lambert  (N.  Y.  State  Jour,  of  Med., 
Jan.,   1910). 

The  belladonna  treatment  properly 
given  will  totally  eradicate  the  physio- 
logical craving  for  narcotic  drugs,  in- 
cluding alcohol.  To  secure  permanent 
results  it  is  necessary  to  pay  as  much 
attention  to  the  after-care  in  both  alco- 
holic and  drug  cases  as  is  given  to  the 
derivative  treatment.  This  after-care 
consists  in  regular  supervision  over 
several  months  and  a  thorough  under- 
standing of  the  needs  of  the  patient  by 
both  himself  and  his  friends.  The 
treatment  consists  in  the  hourly  ad- 
ministration of  a  mixture  of  bella- 
donna, hyoscyamus,  and  xanthoxy- 
lum,  in  connection  with  increasing 
vigorous  catharsis  at  stated  intervals. 
At  the  end  of  this  course  a  so-called 
''typical  stool"  is  obtained,  and  the 
patient  emerges  into  a  very  unusually 
comfortable  condition  with  little  or 
no  craving  remaining.  There  are 
several  points  to  be  noted  about  this 
vigorous  derivative  treatment.  The 
belladonna  mixture  must  be  pushed 
to  the  physiological  limit  and  not 
beyond.  Atropine  poisoning  must  be 
sighted,  but  not  reached.  To  fall 
short  of  this  point  spells  failure  to 
actuall}'  obliterate  the  craving;  to 
overstep  it  intimidates  the  patient. 
Ross  Moore  (So.  Calif.  Pract.,  July, 
19in. 

If  the  restlessness  and  excitement 
continue,  repeat  the  apomorphine 
in  /'20-g'i'ain  doses  every  two  hours. 
Should  the  stomach  be  irritable,  use 
hot    and    cold    fomentations    over    it, 


and  give  carljonated  waters,  usually 
Vichy.  The  patient  should  not  take 
any  food,  for,  as  a  rule,  digestion  is 
impaired  to  the  extent  that  food  can- 
not be  assimilated. 

If  the  patient  is  restless  and  insists 
on  moving  about,  have  an  attendant 
go  with  him  and  walk  him  until  he 
shows  fatigue,  then  bring  him  back 
and  give  a  hot  tub  bath  or  shower 
with  apomorphine  and  strychnine. 

Never  give  chloral  or  morphine. 
The  latter  may  be  used  under  special 
circumstances,  but  the  former  is  con- 
traindicated.  For  the  insomnia  lupu- 
lin,  valerian,  cannabis  indica,  and 
other  vegetable  narcotics  may  be 
given,  but  never  in  the  form  of  tinc- 
tures. 

Often  some  of  these  drugs  produce 
sleep  at  once.  Others  have  little  or 
no  effect  and  should  not  be  given.  The 
size  of  the  dose  will  depend  upon  the 
apparent  sensitiveness  of  the  patient 
to  the  effects. 

Occasionally,  where  there  is  a  tend- 
ency to  delirium,  bromide  of  sodium 
in  from  SO-  to  100-  grain  doses  may 
be  used.  Not  more  than  3  or  4  doses 
at  intervals  of  three  hours  should  be 
given.  After  g-iving  this  drug  the 
patient  should  take  a  hot  bath,  which 
has  the  effect  of  producing  more 
rapid  absorption  of  the  salt.  Some- 
times a  salt  bath  is  preferable  to 
plain  water,  if  there  is  much  de- 
pression. 

Cinchona  bark  in  infusion  has  a 
very  good  effect,  and  infusion  of 
quassia  chips  is  another  remedy  of 
great  value,  but  for  the  acute  stages 
hot  water,  hot  baths  are  most  prac- 
tical. In  the  course  of  a  day  or  so  a 
disgust  for  spirits  begins.  In  the 
mean  time  salines  should  be  given  and 
the  bowels  kept  loose. 


558 


ALCOHOLISM    (CROTHERS). 


The  strychnine  combination  should 
be  kept  up,  and  should  the  atropine 
symptoms  appear  the  size  of  the  dose 
diminished.  Food  should  be  taken 
very  sparingly  for  the  first  two  days. 
After  that  a  diet  rich  in  cereals  and 
malted  milk  may  be  given. 

As  a  rule,  milk  is  not  a  good  diet  for 
these  cases.  Coffee  and  tea  may  be 
used  according  to  the  taste  of  the 
patient.  Exercise  in  the  open  air  and 
reclining  in  a  cool  room,  with  nerve 
rest,  are  very  essential. 

The  disposition  of  the  patient  tO' 
eat  inordinately  should  be  suppressed. 
If  there  is  a  tendency  to  constipation, 
mineral  waters  that  are  laxative  on 
an  empty  stomach  should  be  given. 

Caffeine  is  almost  a  specific  in  alco- 
,  holic  toxemia.     This  drug  in  doses  of 

1  to  2  grains  every  one,  two,  or  three 
hours  will  usually,  in  from  twenty-four 
to   forty-eight  hours,   quench  the  thirst 
or  craving  frr  alcohol  to  such  an   ex- 
tent that  the   most   confirmed  habitues 
will  voluntarily  abandon  its  use.     Four 
cases  are  reported  which  seem  to  uphold 
the    author's    contention.      Hall     (Med. 
News,  Oct.  31,  1903). 
Elimination  through  the  skin,  bow- 
els, and  kidneys  should  be  the  main 
purpose    of   the    treatment,    all    with 
proper    nutrition    and    rest.     Where 
there  is  a  history  of  specific  disease, 
mercury  or  arsenic  in  small  doses  is 
required.     When  the  paroxysm  sub- 
sides and  the  patient  is  restored,  the 
great  question  becomes  to  determine 
the    exciting    causes    which    produce 
the  return  of  the  drink  craze,  and  as- 
certain their  periodicity. 

In  most  cases  it  is  wise  to  discon- 
tinue the  strychnine  compound  and 
continue  the  free  use  of  baths,  care- 
fully regulated  diet,  with  salines,  for 
some  time,  until  evidence  of  the  re- 
turn of  the  drink  craze  appears. 

If  the  patient  keeps  in  close  touch 


with  the  family  physician  his  diges- 
tion, nervous  symptoms,  and  habits 
of  living  can  be  studied  and  properly 
treated.  Where  possible,  Turkish 
baths,  with  prolonged  rest  afterward, 
should  be  given  at  least  once  or  twice 
a  week. 

If  the  physician  can  secure  the  full 
confidence  of  the  friends  as  well  as 
the  patient,  and  impress  upon  him 
the  necessity  of  extraordinary  care 
and  the  methodical  use  of  hydro- 
pathic measures,  a  great  deal  can  be 
accomplished. 

In  the  country,  baths  may  be  im- 
provised in  a  tub,  and  water  falling 
on  the  patient  in  a  narrow  stream 
has  an  excellent  sedative  efifect.  Hot 
packs  or  sheets  wrung  out  in  hot  or 
cold  water  covering  the  body,  over 
which  are  spread  dry  blankets,  pro- 
ducing intense  or  rapid  perspiration, 
are  often  most  valuable. 

The  physician  should  always  study 
the  digestion  of  the  patient  and  de- 
termine the  states  of  acidity  or  alka- 
linity of  the  stomach  and  correct 
them  as  required. 

Exhaustion  and  depression  fre- 
quently precede  a  drink  impulse. 
Small  doses  of  ipecac,  ^  of  a  grain 
given  at  intervals  of  two  hours,  pro- 
duce a  pronounced  relaxing  efifect, 
and  where  the  patient  has  high-ten- 
sioned  arteries  and  excitable  pulse 
this  is  an  excellent  remedy. 

Quassia  chips  in  a  concentrated  so- 
lution are  almost  a  specific  for  the 
drink  craze,  but  they  must  be  given  in 
large  doses  at  intervals  of  an  hour  or 
so,  and  followed  by  free  use  of  ca- 
thartics and  baths.  Quinine  has  some 
value,  particularly  where  there  is  a 
history  of  malaria,  but  it  should  not 
be  used  more  than  two  or  three 
weeks. 


ALCOHOLISM    (CROTHERS). 


559 


All  such  cases  are  self-limited  and 
will  recover  with  the  use  of  h3^gienic 
measures.  The  great  value  of  the 
physician  is  to  determine  and  remove 
the  causes  and,  where  there  is  a  peri- 
odicity in  the  return  of  the  paroxysm, 
to  have  the  patient  under  treatment 
and  anticipate  this  condition. 

The  nervous  disturbance  of  drug 
habitues  depending  upon  the  disturbance 
of  the  vascular  system,  the  indication  is 
to  bring  about  promptly  an  equilibrium 
of  the  circulation,  and  for  doing  this 
the  hypodermic  injection  of  ergot  is 
the  most  certain  method.  Ergot  con- 
tracts the  muscular  coats  of  the 
blood-vessels,  but  its  most  pro- 
nounced action  is  upon  areas  of  such 
tissue  as  is  weak  and  relaxed,  and, 
hence,  its  action  on  dilated  blood- 
vessels is  peculiarly  satisfactory. 
The  first  step  in  the  treatment  of  these 
drug  habits  is  to  discontinue  the  use  of 
the  narcotic,  or  of  any  substitute  there- 
for. The  use  of  ergot  is  begun  at 
once,  giving  a  purgative  at  the  same 
time,  and  the  bowels  are  kept  open. 
In  general,  2  or  3  doses  of  ergot  of  Yz 
dram  each  of  a  solution  consisting  of 
1  dram  of  the  extract  dissolved  in  an 
ounce  of  water  are  given  daily,  but  in 
extreme  cases  it  may  be  necessary  to 
employ  the  drug  at  intervals  of  two 
hours.  The  ergot  method  acts  ad- 
mirably in  the  morphine  habit,  the  most 
difficult  of  all  to  cure.  A.  T.  Living- 
ston  (Merck's  Archives,  Nov.,  1903). 

The  writer  carries  out  the  "gold  cure" 
for  alcoholism  in  the  following  man- 
ner :  The  patient  is  put  tmder  the 
pleasantest  surroundings,  no  restraint 
whatever  is  used,  and  he  is  allowed  all 
the  alcohol  he  wishes.  Atropine  (or 
daturine)  and  strychnine  are  given 
hypodermically,  and  a  mixture  of 
chloride  of  gold  and  sodium,  ammo- 
nium chloride,  aloin,  viburnum,  and 
cinchona  is  given  every  two  hours 
during  the  day.  By  the  fifth  day  the 
patient  voluntarily  abstains  from  al- 
cohol, and  at  the  end  of  four  weeks 
the  drink-sodden  victim  of  intem- 
perance is  transformed  into  a  healthy 


and  sober  man.  The  treatment  is 
necessarily  institutional  from  its  very 
nature.  Of  the  author's  patients  he 
estimates  that  60  per  cent,  remain  total 
abstainers.  Fenn  (Brit.  Med.  Jour., 
April  30,  1904). 

The  treatment  of  drug  and  alcohol 
habitues  with  hyoscine  will  remove 
the  desire  for  these  drugs,  thus 
eliminating  the  element  which  pre- 
vents the  patients  from  abstaining 
by  force  of  will  power.  Having  lost 
the  desire,  they  do  very  well  without 
intoxicants  or  the  drugs,  as  shown 
by  the  increase  in  appetite,  gain  in 
flesh,  and  their  general  improvement. 
The  question  of  relapse  lies  entirely 
in  the  sincerity  and  environment 
of  the  patient.  The  favorable  alcoholic 
addicts  are  those  who  earnestly  desire 
to  discontinue  the  use  of  intoxicants 
and  are  willing  to  change  their  mode  of 
living  and  environment,  but  who  can- 
not until  relieved  of  the  craving  for 
liquor.  Relapse  in  both  drug  and  liquor 
cases  is  not  due  to  a  desire  nor  suffering 
after  the  treatment,  but  to  their  curi- 
osity to  test  the  necessity  of  total  ab- 
stinence, or  to  the  temptations  of  social 
life.  A  single  dose  of  the  drug  or  drink 
of  liquor,  even  after  one  year  of  total 
abstinence,  is  very  apt  to  start  the 
craving,  resulting  in  a  condition  which 
is  no  better  than  before  treatment. 
This  method  may  prove  a  valuable 
treatment  in  apparently  hopeless  cases 
of  opium  poisoning.  Interesting  experi- 
ments along  this  line  might  be  carried 
out.  The  one  contraindication  for  this, 
treatment  is  the  presence  of  Bright's 
disease.  No  patient  should  be  treated 
unless  put  to  bed  and  watched  by  com- 
petent nurses  day  and  night  during  the 
first  week.  Riewel  (Monthly  Cyclo. 
and  Med.  Bull.,  Oct.,  1909). 

In  delirium  opium  and  its  deriva- 
tives and  many  of  the  other  drugs 
that  are  powerful  narcotics  should  be 
avoided.  All  proprietary  drugs  are 
dangerous,  and  should  be  condemned 
no  matter  what  the  experience  may 
be.  Every  physician  is  capable  of  do- 
ing far  more  for  the  relief  of  this  con- 


560 


ALCOHOLISM    (CROTHERS). 


dition  by  adapting  the  remedies  to 
the  particular  case  than  by  any  widely 
exploited  compound. 

[Workhouse  hospitals  for  inebriates  are 
just  being  recognized  and  will  take  the  place 
of  the  present  ruinous  jail  and  fines  sys- 
tem of  the  courts.  Nothing  is  more 
unscientific  than  treating  the  inebriate  as 
a  moral  delinquent  and  punishing  him  as 
though  sound  and  capable  of  doing  other- 
wise. 

All  physicians  should  protest  vigorously 
against  this  relic  of  barbarism,  and  insist 
that  the  alcoholic  be  cared  for  in  hospitals, 
the  same  as  any  other  sick  person.  Every- 
where a  new  field  of  practice  is  evident,  and 
the  possible  restoration  of  a  large  number 
of  the  drink  and  drug  ukers  is  absolutely 
certain  from  a  larger  knowledge  and  more 
exact  study  of  their  conditions. 

The  important  fact  should  be  recog- 
nized that  at  least  70  per  cent,  of  all 
inebriates  and  alcoholics  are  of  the  de- 
fective, degenerate  classes  whose  condi- 
tions are  the  result  of  causes  pronouncedly 
physical  and  preventable  with  more  exact 
study  and  knowledge.  The  remaining  30 
per  cent,  are  the  victims  of  circumstances, 
surroundings,  and  conditions  which  are 
equally  preventable.  In  this  field  there 
are  possibilities  of  successful  treatment 
and  prevention  that  will  exceed  all  ex- 
pectations.   T.  D.  Crothers.] 

ACUTE  ALCOHOLIC  DELIR- 
IUM, OR  DELIRIUM  TREMENS. 

This  is  a  condition  of  acute  alcoholic 
poisoning,  associated  with  exhaustion 
and  cell  starvation.  It  occurs  chiefly 
in  habitual  drinkers,  but  it  is  also  ob- 
served in  ordinary  temperate  per- 
sons after  a  prolonged  drinking  spell. 
Though  mostly  met  with  in  spirit 
drinkers,  it  is  occasionally  seen  in  beer, 
wine,  and  cider  drinkers. 

SYMPTOMS.— Two  forms  are  dis- 
tinguished :  the  traumatic  and  the  idio- 
pathic. They  differ  little  except  in  the 
prodromata.  In  the  traumatic  form, 
after  an  accident  (sometimes  only 
slight  trauma)  the  characteristic  tre- 
mors, etc.,  appear,  frequently  without 


^varning.  In  the  idiopathic  form,  the 
patient  who  is  about  to  have  an  attack 
is  restless,  uneasy,  irritable ;  he  sleeps 
badly,  if  at  all,  suffers  from  digestive 
troubles,  and  has  little  desire  for  food. 
Delirium  then  appears.  The  patient 
cannot  rest,  but  must  be  in  constant 
motion.  He  is  shaking  all  over  ("the 
shakes"),  is  consumed  with  terrors, 
continually  in  deadly  fright  of  things 
which  he  mentally  sees,  or  of  persons 
whom  he  thinks  are  after  him  for  the 
commission  of  some  crime.  At  other 
times  his  dread  is  of  something  terrible, 
though  he  cannot  tell  what  it  is.  He  is 
all  the  while  trying  to  escape  from 
these  well-defined  or  undefined  horrors, 
and,  in  the  attempt  to  escape,  fatal- 
ities sometimes  occur.  Hallucinations 
of  sight  are  most  common :  snakes, 
rats,  mice,  loathsome  things,  flames, 
and,  in  a  case  of  the  writer's,  roaring 
lions  bounding  down  the  chimney,  be- 
low the  chairs,  and  rushing  in  at  the 
windows.  According  to  Liepmann, 
visions  of  animals  are  present  in 
40  per  cent,  of  cases  at  most.  The 
delirium  is  best  described  as  one  of 
busy  w^akefulness  and  suspicion. 
There  is  a  third  non-febrile,  innocent 
form,  in  which  the  temperature  does 
not  rise  above  100°  F. 

Hallucinations  of  hearing  are  not  so 
common,  but  exist  in  probably  10  to  20 
per  cent,  of  cases.  Delusions  (false 
perceptions  concerning  self)  are  found 
in  from  5  to  9  per  cent., — mostly  delu- 
sions of  persecution.  Sometimes  there 
is  one  hallucination,  illusion,  or  delu- 
sion throughout;  sometimes  thene  is  a 
succession.     . 

The  tongue  is  white  and  furred. 
Tremor  of  this  organ,  and  especially  of 
other  muscles,  is  a  more  or  less 
marked  and  generally  present  symp- 
tom. 


ALCOHOLISM    (CROTHERS). 


561 


The  fever  is  not  very  high,  being- 
about  100°  to  103°  F.  If  higher,  it  is 
an  unfavorable  omen.  The  pulse  is 
soft,  rapid,  and  readily  compressed. 
The  skin  is  clammy.  Insomnia  is  con- 
stantly present,  but  usually  sleep  and 
improvement  occur  on  the  third  or 
fourth  day.  In  unfavorable  cases  the 
patient  grows  gradually  worse  and  dies 
of  heart-failure    (Norman  Kerr). 

Anabasis  of  the  material  of  the  Mos- 
cow Clinic  as  regards  the  statistics  of 
alcoholic  delirium.  Only  cases  of 
chronic  alcoholic  delirium  in  which  the 
presence  of  insanity  of  any  other  type 
could  be  excluded  were  utilized.  Out 
of  4813  insane  registered  in  the  clinic 
since  its  opening,  it  was  found  that 
there  had  been  33  cases  of  chronic 
alcoholic  delirium.  Of  these,  30  were 
in  men  and  3  in  women.  Of  29  cases 
in  which  the  heredity  was  noted 
20  showed  alcoholism  in  the  parents, 
principally  in  the  father;  3  patients 
showed  nervous  or  mental  diseases 
in  the  immediate  family.  Heredity 
was,  therefore,  present  in  96.55  per 
cent.,  and  these  figures,  according  to 
the  authors,  showed  conclusively 
enough  the  hereditary  nature  of 
chronic  alcoholism.  So  far  as  the 
small  number  of  cases  observed  war- 
rants a  conclusion,  chronic  alcoholic 
delirium  develops  much  later  in  life 
in  women  than  in  men,  and  this  is  be- 
cause the  women  begin  to  abuse  liquor 
much  later  than  men.  Soukhanoff  and 
Vvedenski  (Roussky  Vratch,  July  12, 
1903). 

Case  of  death  from  delirium  tre- 
mens after  a  slight  fall  whicli  without 
this  complication  would  have  been 
comparatively  harmless.  The  spon- 
taneous pain  of  the  contusion  sub- 
sided under  repose  by  the  second 
day,  but  then  delirium  tremens  de- 
veloped, fatal  on  the  sixth  day.  The 
writer  has  witnessed  a  number  of 
cases  of  this  kind  and  discusses  the 
question  from  the  standpoint  of  acci- 
dent insurance.  There  can  be  no 
question  as  to  the  connection  be- 
tween the  accident  and  the  develop- 


ment     of      the      fatal      complication. 
Forgue  (Presse  med.,  July  24,  1909). 

Delirium  tremens,  other  conditions 
being  equal,  attacks  males  and  fe- 
males alike.  The  greatest  number  of 
cases  was  found  at  an  age  between 
31  and  45  years.  A  congenital  psycho- 
pathic diathesis  is  not  uncommon  in 
patients  having  delirium  tremens. 
Epilepsy  is  extremely  frequent  as  a 
sequela  of  alcoholism,  and  was  re- 
peatedly noted  in  these  cases.  There 
are  numerous  epileptics  from  abuse 
of  alcohol,  however,  who  never  de- 
velop delirium  tremens;  and  on  the 
other  hand,  many  individuals  suffer- 
ing from  delirium  tremens  have  never 
had  an  epileptic  seizure.  Epilepsy 
was  noted  in  43.66  per  cent,  of  the 
delirium  tremens  cases.  Among  284 
cases  observed  by  the  writer,  there 
were  27  deaths,  9.5  per  cent.  The 
principal  danger  is  of  heart-failure, 
and  in  these  cases  there  is  no  objec- 
tion to  the  medicinal  use  of  alcohol. 
Wassermeyer  (Archiv  f.  Psychiatric, 
Bd.  xliv,  1909). 

DIAGNOSIS.— Alcoholic  delirium 
may  be  mistaken  for  the  delirium  of 
meningitis,  of  typhus  and  typhoid 
fevers,  and  of  chronic  alcoholism. 
The  history  and  progress  of  the  case 
determine  the  first  two,  and  the  ab- 
sence or  significance  of  thirst,  tongue 
trembling,  and  tremors  the  third. 

Pulmonary  disorders ;  congestion,  es- 
pecially when  of  traumatic  origin,  and 
pneumonia  may  also  give  rise  to  delir- 
ium simulating  that  of  delirium  tre- 
mens. Fractured  ribs  may  thus  become 
the  primary  factor  of  violent  accesses. 
The  same  may  be  said  of  erysipelas. 

PATHOLOGY.— Acute  alcoholism 
is  due  to  gradually  produced  changes 
in  the  nerve-tissues,  and  especially  to 
retained  products  of  metabolism.  The 
cerebral  lesions  in  alcoholic  delirium 
are  of  'two  varieties.  The  first  is 
observed  in  all  alcoholics,  and  is  due 
to  the  alcohol  itself:  atheromatous  de- 

1—36 


562 


ALCOHOLISM    (CROTHERS). 


generation  of  the  vessels,  the  degree  of 
disorder  increasing  as  the  cahber  of 
the  vessel  is  reduced.  The  nerve-cells 
also  show  granular  pigmentation  and 
fatty  degeneration. 

The  second  variety  is  derived  spe- 
cially from  the  character  of  the  delir- 
ium, and  not  from  the  alcohol  itself.  It 
consists  in  congestion,  hematic  pigmen- 
tation in  the  capillaries  and  nerve-ele- 
ments, and  degeneration  of  the  nerves 
and  fibers  of  the  corttex,  the  precursors 
of  general  paralysis  (Norman  Kerr). 

According  to  Jacobson,  delirium 
tremens  occurs  when  a  brain,  deterio- 
rated by  chronic  alcoholism,  is  influenced 
by  a  toxic  agent,  either  due  to  the  action 
of  bacteria  or  to  autointoxication  from 
diseases  of  the  digestive  tract,  the  kid- 
neys, or  the  liver. 

The  changes  in  the  central  nervous 
system  and  spinal  ganglia  are  quite 
uniform;  they  consist  essentially,  first, 
in  thickening  of  the  walls  of  the 
arteries,  proliferation  of  the  connective 
tissue  in  the  media,  and  dilatation  and 
infiltration  of  the  lymph-spaces.  These 
changes  are  more  pronounced  in  the 
cortex,  and  frequently  lead  to  minute 
hemorrhages,  as  many  as  200  of  these 
having  been  counted  in  a  square  centi- 
meter of  the  cortex.  The  capillaries 
appeared  to  be  proliferated,  particu- 
larly in  1  case,  but  they  and  the  veins 
showed  no  pronounced  anatomical  al- 
teration. The  neuroglia  fibers  of  the 
cortex  showed,  according  to  Weigert's 
new  method,  considerable  proliferation. 
The  Weigert  cells  were  more  numerous 
than  normal.  The  free  nuclei,  both  the 
small  and  large  varieties,  were  in- 
creased in  number  in  the  second  and 
sixth  layer  of  the  cortex,  and  appeared 
to  be  accumulated  around  the  degener- 
ating cells.  The  spinal  cord  was  ap- 
parently liormal  (Tromner). 


Of  247  recovered  personal  cases  of 
delirium  tremens  studied  by  Jacobson, 
202  were  uncomplicated  and  45  compli- 
cated by  other  diseases.  Although  the 
delirium  tremens  cannot  be  regarded  as 
caused  by  the  action  of  the  pneumo- 
coccus,  it  resembles,  in  all  its  features, 
an  infectious  disease :  it  has  a  stage  of 
incubation — a  duration  of  about  four 
days ;  it  ends  with  a  critical  sleep ;  is 
accomlpanied  by  rise  of  temperature, 
and  almost  in  all  cases  by  albuminuria, 
and  when  autopsy  is  made  the  spleen 
is  generally  found  to  be  the  seat  of 
parenchymatous  degeneration,  as  well 
as  the  heart,  the  kidneys,  and  the  liver. 

PROGNOSIS.— In  private  practice 
the  prognosis  is  favorable  in  ordinary 
cases;  in  hospital  practice  it  is  much 
less  so.  Of  1241  cases  admitted  to  the 
Philadelphia  Hospital  during  a  fixed 
period,  121  died.  Recurrence  occurs  if 
drinking  is  continued.  Norman  Kerr 
noted  recurrence  from  one  to  five  times 
in  104  out  of  442  cases  treated  in  a  spe- 
cial institution. 

TREATMENT.— The  first  indica- 
tion is  to  remove  the  causative  tox- 
emia; this  can  be  done  by  persistent 
and  active  hydropathic  measures. 
Hypnotics  are  not  always  necessary, 
and  may  be  dangerous.  They  should 
be  avoided  if  possible.  The  best  treat- 
ment is  continuous  baths,  showers,  sa- 
lines, restraint,  exercise,  massage,  good 
air,  and  little  or  no  food  until  the  de- 
lirium subsides.  The  following  repre- 
sents, however,  the  measures  generally 
recommended  in  such  cases : — 

The  patient  must  be  kept  in  bed 
and  carefully  watched.  Strapping  in 
bed  should  not  be  practised,  as  the 
restraint  causes  muscular  movements 
and  delirium.  A  sheet  tied  across  the 
bed  is  preferable,  as  this  allows  more 
freedom  of  motion.    Attendants  or  a 


ALCOHOLISM    (CROTHERS). 


563 


padded  room  is  best  of  all.  No  alco- 
hol should  be  given,  the  strength  be- 
ing sustained  by  foods,  milk,  soups, 

etc. 

The  immediate  suppression  of  alco- 
hol in  delirium  tremens  and  the  em- 
ployment of  hydrotherapeutic  meas- 
ures advised  rather  than  of  hyp- 
notics; the  former  serve  to  increase 
and  to  maintain  the  activity  of  the 
heart,  although  one  would  expect  an 
opposite  effect.  In  instances  of  car- 
diac weakness  stimulants,  strophan- 
thus,  digitalis,  camphor,  caffeine,  are 
employed,  and  in  about  three  days, 
when  the  delirium  begins  to  lessen, 
30  to  60  grains  of  chloralformamide 
are  given;  this  quickly  induces  sleep. 
Thirst  is  controlled  by  bitter  infu- 
sions. If  pneumonia  appears  as  a 
complication,  digitalis  and  alcohol 
are  administered.  In  these  patients  the 
prognosis  is  distinctly  bad.  Eichelberg 
(Miinch.  med.  Woch.,  Bd.  xx,  S.  978, 
1907). 

Potassium  bromide,  ^/o  dram,  v^^ith 
tincture  of  capsicum  given  every 
three  hours,  is  recommended  for  mild 
cases  by  Osier. 

Sleep  is,  however,  deemed  neces- 
sary by  some  authorities.  According 
to  Lancereaux,  for  example,  the  real 
chance  of  recovery  in  alcoholic  de- 
lirium lies  in  sleep.  The  patient  is, 
therefore,  isolated  in  a  quiet,  dark,  and, 
if  necessary,  padded  room,  no  physical 
restraint  being  employed.  To  procure 
sleep  the  patient  is  given  1  to  1^4 
drams  of  chloral  hydrate,  with  ^ 
grain  of  hydrochlorate  of  morphine, 
in  an  infusion  of  limes.  If  sleep  does 
not  come  on  in  about  ten  minutes,  from 
Yq  to  %  grain  of  morphine  is  injected 
hypodermically.  After  the  alcoholic 
disturbance  has  subsided  strychnine 
or  nux  vomica  is  given,  followed  by 
hydrotherapeutic  measures.  If  there 
should  be  gastric  complication,  an 
antacid,  such  as  sodium  bicarbonate, 
is  administered. 


The  author  describes  the  treatment- 
that  he  uses  in  cases  of  delirium  tre- 
mens. The  patient  is  stripped  naked 
and  lies  on  a  blanket  over  a  waterproof 
sheet.  A  copious  supply  of  ice-cold 
water  is  provided,  and  a  large  bath 
sponge  dripping  with  the  iced  water  is 
dashed  violently  on  the  face,  neck, 
chest,  and  body  as  rapidly  as  possible. 
He  is  then  rubbed  dry  with  a  rough 
towel,  and  the  process  is  repeated  a 
second  and  a  third  time.  The  patient 
is  now  turned  over,  and  the  wet  sponge 
is  dashed  on  the  back  of  the  head  and 
down  the  whole  length  of  the  spine  two 
or  three  times,  vigorous  friction  with 
a  bath  towel  being  employed  between 
the  cold-water  applications.  By  the 
time  the  patient  is  dried  and  made 
comfortable,  he  will  be  fast  asleep. 
William  Broadbent  (Brit.  Med.  Jour., 
July  1,  1905). 

The  writer  reports  the  result  of 
five  years'  use  of  veronal  in  delirium 
tremens.  His  method  of  administra- 
tion is  as  follows:  An  initial  dose  of 
1  Gm.  -is  given  in  all  incipient  cases. 
If  sleep  does  not  follow  within  three 
hours,  another  gram  is  given.  Sleep 
then  follows  and  lasts  six  to  eight 
hours,  or  even  twelve.  On  waking 
the  patient  is  clear,  quiet,  and  feels 
well.  If  there  is  yet  some  tremor, 
0.5  Gm.  of  veronal  is  given,  and  by 
evening  all  tremor  has,  as  a  rule,  dis- 
appeared. If  the  patient  remains  in 
the  hospital  some  time  longer  for 
other  reasons,  0.5  Gm.  is  given  every 
evening  to  insure  against  sleepless- 
ness. If  the  delirium  is  not  con- 
trolled from  the  2  Gm.  as  given  above, 
another  gram  may  be  given  five  to 
six  hours  after  the  second  dose. 
Only  3  patients  have  failed  to  re- 
spond to  this  treatment  out  of  a 
total  of  100.  There  were  2  deaths 
from  double  pneumonia.  In  all  the 
author's  experience  he  has  only  seen  1 
case  of  veronal  rash,  and  absolutely 
no  other  symptoms  of  veronal  poison- 
ing. V.  F.  Moller  (Berl.  klin.  Woch., 
Dec.  27,  1909). 

Delirium  tremens,  on  alcoholic 
basis,  even  in  strong  men  of  middle 
age,  is  a  serious  illness,  with  a  mor- 


564 


ALCOHOLISM    (CROTHERS). 


tality  variously  stated  as  3  to  19  per 
cent.  The  writer  treated  396  cases 
from  1901  to  1906  with  chloral  hydrate 
(1  to  3  grains)  and  with  bromides. 
Digitalis  was  given  only  when  neces- 
sary, and  alcohol  was  withheld.  The 
mortality  was  9  per  cent.  Of  the 
cases,  17.4  per  cent,  belonged  to  the 
type  of  delirium  imminens.  Between 
1907  and  1909,  264  cases  were  treated 
almost  exclusively  with  veronal.  The 
drug  was  dissolved  in  warm  tea. 
Soon  after  admission  the  patient  re- 
ceived 1  Gm.  (15  grains),  and  one  to 
two  hours  later  a  second  gram.  If 
necessary,  a  third  gram  is  adminis- 
tered within  five  hours  and  a  fourth 
gram  within  twelve  hours.  There 
never  was  the  slightest  untoward 
effect  on  pulse  or  respiration.  The 
mortality  sank  to  3.4  per  cent.;  the 
percentage  of  cases  where  the  de- 
lirium could  be  prevented  rose  to  28. 
The  majority  of  fatal  cases  already 
suffered  from  pneumonia.  This  ob- 
servation proves  that  veronal  is  far 
superior  to  chloral  and  bromides  to 
check  the  attack  in  its  incipiency,  and 
also  to  prevent  a  fatal  issue.  Ernst 
V.  d.  Porten  (Therap.  d.  Gegenwart, 
June,  1910;  Merck's  Archives,  Nov., 
1910). 

Incipient  cases,  with  insomnia,  rest- 
lessness, tremor,  occasionally  hal- 
lucinations, should  receive  large  doses 
of  hypnotics,  preferably  veronal; 
whisky  should  be  given  regularly,  and 
ergot  at  frequent  intervals,  either  by 
intramuscular  injection  or  by  mouth. 
Discontinue  medication  gradually,  and 
only  after  all  restlessness  and  tremor 
has  disappeared.  More  advanced 
cases,  with  marked  delirium,  inco- 
ordination, usually  fever,  slight  leuco- 
cytosis,  and  profuse  perspiration, 
should  receive  veronal  in  moderate 
doses;  also  ergot.  Ranson  and  Scott 
(Amer.  Jour.  Med.  Sci.,  May,  1911). 

It  must  not  be  forgotten,  however, 
that  large  doses  of  narcotics,  with  the 
cardiac  depression  apt  to  follow  their 
exhibition,  are  dangerous,  especially 
in  the  aged  and  infirm  inebriates. 
Kerr    preferred     repeated     doses    of 


liquor    ammoniae    acetatis     (B.    P.), 

Sleep,  thus  quietly  and  safely  in- 
duced, has  proved  much  more  cura- 
tive than  narcotics  in  his  practice. 

Trional  and  opium,  if  given,  should 
be  administered  cautiously. 

If  fever  is  present,  the  cold  douche, 
bath,  or  preferably  the  wet  pack  may 
be  tried.  If  the  pulse  becomes  too 
rapid  and  weak,  very  small  doses  of 
digitalis  in  aromatic  spirit  of  ammo- 
nia should  be  given.  Digitalis  in  large 
doses  is  dangerous  (Osier,  Delpeuch, 
Kerr). 

The  author  witnessed  the  collapse 
and  death  of  a  robust  man  in  delirium 
tremens  while  being  given  a  prolonged 
warm  bath.  One  of  his  patients  suc- 
cumbed in  collapse  during  a  wet  pack, 
and  he  has  consequently  abandoned 
these  measures.  In  treatment  of  1051 
cases  of  delirium  tremens  in  the  last 
sixteen  years,  he  has  made  it  a  rule  to 
allow  no  alcohol.  In  the  first  series  of 
486  cases  the  mortality  was  6.37  per 
cent.,  while  in  the  last  565  cases  it  has 
been  only  0.88  per  cent.  He  ascribes  this 
improvement  in  the  results  to  his 
observation  of  the  fact  that  the  cause 
of  death  in  delirium  tremens  is  gen- 
erally paralysis  of  the  heart,  and  he 
now  addresses  treatment  to  the  heart 
regardless  of  whether  cardiac  symp- 
toms are  apparent  or  not.  The  agita- 
tion and  motor  excitement  react  on 
the  heart,  and  signs  of  heart  weakness 
soon  become  manifest.  He  makes  it  a 
rule  to  give  digitalis  from  the  very 
first,  giving  1.5  Gm.  in  an  infusion  in 
the  course  of  the  da^^  and  repeating 
this  dose  two  or  three  times.  If  it  can- 
not be  given  by  the  mouth,  he  gives  it 
in  a  rectal  injection.  At  the  first  signs 
of  heart  weakness  other  heart  tonics 
are  used;  1  Gm.  of  camphorated  oil  is 
injected  subcutaneously  every  hour  or 
so  until  the  critical  symptoms  subside. 
A  tablespoonful  of  ice-cold  cham- 
pagne every  half-hour  was  also  found 
useful — the  only  way  in  which  he 
allows  alcohol.  To  promote  the 
washing    out    of    the    toxins    causing 


ALCOHOLISM    (CROTHERS). 


565 


the  attack,  he  has  the  patients  drink 
copiously,  and  supplies  them  for  the 
purpose  with  a  drink  which  has  the 
color  of  beer  and  tastes  refreshing, 
and  is  taken  eagerly  by  the  delirious 
patient.  It  is  merely  a  1  per  cent, 
solution  of  sodium  acetate  in  water 
to  which  a  little  common  syrup  has 
been  added.  S.  Ganser  (Miinch.  med. 
Woch.,  Bd.  liv,  Nu.  3,  1907). 

The  writer  ascribes  the   symptoms 
of  this  condition  to  the  accumulation 
of  toxic  products,  autogenous  as  well 
as    alcoholic,   in  the   blood.     Accord- 
ingly, he  aims  at  the  removal  of  these 
deleterious  substances.    He  gives  nor- 
mal salt  solution  in  large  quantities 
by  the  rectum,  hypodermically,  or,  if 
necessary,    intravenously.      Thus    the 
entire    circulatory    system    is    flushed 
with  fluid  to  its  utmost  capacity,  and 
this  is  then  relieved  by  free  purgation 
with     large     and    repeated     doses     of 
Epsom  salt.    Calomel  in  full  doses  is 
also  given.     Sparteine  is  administered 
in  2-grain   doses   for  the   purpose   of 
supporting  the   heart   and  promoting 
diuresis.     For  the   delirium   itself   gel- 
semine  is  given  every  hour,  or  every 
two     hours,     until     its     physiological 
effect  is  produced;   the  dose  advised 
is  %5   grain.     Alcohol   is   reduced  to 
moderate   limits,   but   is   not    entirely 
withdrawn:      opium    and    other    nar- 
cotics  are  condemned  as  not  merely 
dangerous,  but  useless.     Physical  re- 
straint is  also  held  to  be  not  permis- 
sible.     In   450   consecutive    cases   the 
results  of  this   line   of  treatment  are 
described  as  excellent,  and  no  death 
from    delirium    tremens    occurred    in 
the  whole  series.     G.  E.  Pettey  (The 
Hospital,  Jan.  15,  1910). 
The  patient  should  be  carefully  fed, 
milk   and   concentrated  broths   being 
especially  useful.    If  necessary,  nutri- 
ent enemata  are  to  be  administered. 

Excellent  is  hypodermoclysis  or  the 
intravenous  infusion  of  saline  solution 
in  dehrium  tremens,  which  increase 
the  amount  of  the  circulating;  medium 
in  which  the  toxic  materials  are  dis- 
solved,  thereby    diluting   the    poison 


and  bathing  the  nerve-centers  with 
a  more  attenuated  solution  of  the 
same.  The  amount  of  circulating  fluid 
is  increased  above  the  normal,  so  that 
the  excretion  of  fluids  through  all  the 
eliminatory  channels  is  augmented, 
thereby  carrying  off  in  solution  much  ' 
of  the  contained  toxins.  The  action  of 
the  heart  is  improved  by  the  filling  of 
the  relaxed  vessels.  These  suffice  to 
restore  the  physiological  equilibrium 
and  turn  the  balance  in  favor  of  recov- 
ery (Warbasse,  Ouenu). 

[Delirium  without  hallucinations,  and  hal- 
lucinations alone  without  any  particular  de- 
lirium are  conditions  that  require  special 
study  and  care.  The  physician  should  not 
permit  such  cases  to  go  about  without 
special  attendants  and  watchful  care. 

Under  all  circumstances  they  need  the 
closest  watching  and  are  really  dangerous, 
unless  guarded,  not  only  to  themselves,  but 
others.  A  delusional  alcoholic  should  be 
guarded  all  the  time,  for  the  reason  that 
dangerous  'obsessions  may  appear  any  mo- 
ment.    T.  D.  Crothees.] 

ACUTE  ALCOHOLIC  MANIA 
(MANIA  A  POTU). 

SYMPTOMS.  — The  patient,  in 
a  wild,  ungovernable  fury,  shouts, 
stamps,  strikes,  or  kicks,  and  is,  for  the 
moment,  uncontrollable.  The  eyes  roll, 
the  face  is  flushed,  and  the  veins  dis- 
tended and  engorged;  the  muscles  are 
at  their  highest  point  of  tension,  and 
are  in  continuous,  violent  action.  The 
pulse  is  strong,  bounding,  and  tumultu- 
ous. Though  mechanically  conscious, 
the  subject  is  filled  with  "blind  fury." 
He  is  carried  away  in  a  tempest  of  nerv- 
ous excitation  and  passion.  The  par- 
oxysms of  violence  sometimes  last  only 
a  few  minutes,  at  other  times  for  from 
an  hour  to  several  days,  with  quiet 
intermissions.  Rarely  are  there  delu- 
sions, though  the  infuriated  subject 
may  vent  his  violence  on  the  first  ani- 
mate or  inanimate  object  in  his  way. 


566 


ALOES   (SAJOUS). 


In  a  few  cases  the  fury  is  directed 
against  a  certain  person  or  tiling.  Vio- 
lence is  succeeded  by  calm ;  a  few  min- 
utes after  a  storm  the  temperature  is 
normal,  and  during  the  paroxysm 
rarely  raised.  In  some  constitutions  a 
paroxysm  may  be  provoked  by  a  small 
quantity  of  alcohol  (Kerr). 

DIFFERENTIAL  DIAGNOSIS. 
— It  may  be  differentiated  from  delir- 
ium tremens  by  the  absence  of  tremors, 
terror,  hallucinations,  delusions,  the 
white  tongue,  nausea,  and  the  delirium 
of  the  latter.  Further,  mania  a  potu 
may  arise  from  a  small  quantity  of  an 
intoxicant  taken  in  a  short  time,  while 
delirium  tremens  is  due  to  large  quan- 
tities taken  in  rapid  succession,  or 
from  smaller  quantities  long  continued 
(Kerr). 

ETIOLOGY  AND  PATHOL- 
OGY.— Mania  a  potu  is  occasionally 
seen  in  chronic  inebriates,  and  most 
frequently  in  periodic  tipplers.  In  the 
latter  it  often  occurs  when,  after  an 
interval  of  abstinence,  an  intoxicant 
is  freely  partaken  of.  Some  chronic 
inebriates  invariably  suffer  acute  mania 
if  they  drink  a  single  glass  of  spirits, 
wine,  or  beer  beyond  their  usual  allow- 
ance. 

The  paroxysms  of  acute  mania 
resemble  those  of  epilepsy,  and  a  large 
proportion  of  police-court  drunken  of- 
fenders are  patients  of  this  class.  The 
symptoms  are  evoked  by  the  patho- 
logical action  of  acute  alcoholic  in- 
toxication on  nervous  systems  liable 
to  such  excitation,  either  oongenitally 
or  from  the  effects  of  intemperance, 
traumatism,  or  brain-tire.  According 
to  Jones,  the  forms  of  insanity  met 
with  which  result  from  alcoholism 
are:  1,  amnesic;  2,  delusional  and,  3, 
chronic  varieties  which  end  in  de- 
mentia. 


PROGNOSIS.  — The  prognosis  is 
much  more  favorable  than  in  ordinary 
acute  mania,  the  paroxysm  usually 
rapidly  passing  away,  leaving  the  pa- 
tient exhausted  and  peaceful.  Unless 
alcohol  be  taken  again  relapse  is  rare. 

TREATMENT.— But  little  treat- 
ment is  generally  needed  in  this  con- 
dition. Non-alcoholic  liquids,  such  as 
milk,  iced  milk,  milk  and  soda,  or 
saline  draughts  with  ipecacuanha  and 
bromides  are  sufficient  to  bring  about 
recovery.  Sometimes  cold  affusions 
and,  in  prolonged  paroxysms,  wet 
packs  prove  valuable  adjuncts. 

When  violent  mania  is  present,  apo- 
morphine,  %  to  %  grain,  hypodermic- 
ally,  causes  nausea  and  vomiting  and 
rapid  removal  of  the  violent  symp- 
toms. 

If  it  persists,  potassium  bromide,  in 
30-grain  doses  every  two  hours,  or 
morphine,  %  grain  at  long  intervals, 
must  be  resorted  to. 

T.  D.  Crothers, 

Hartford. 


ALEPPO  BOIL. 

Sore. 


See  Oriental 


ALOES  (Aloe).— The     inspissated 

juice  of  the  leaves  of  Aloe  vera  or 
A.  chinensis  (Curagao  or  Barbadoes 
aloes)  or  of  other  species,  such  as  Aloe 
Perryi  (socotrine  aloes,  East  Africa) 
and  Aloe  spicata  or  A.  ferox  (Cape 
aloes).  The  plants  are  indigenous  in 
Africa  and  India,  and  are  naturalized 
in  the  West  Indies  and  along  the  Med- 
iterranean shores. 

PROPERTIES  AND  CONSTIT- 
UENTS.— Curaqao  aloes  occurs  in 
orange-brown,  opaque,  and  resin-hke 
masses  which  give  off  an  odor  of  saf- 
fron and  have  a  very  bitter  and  some- 
what nauseous  taste.  Socotrine  aloes 
varies   in  color  from  yellowish  brown 


ALOES    (SAJOUS). 


56; 


to  dark  brown ;  its  odor  and  taste  are 
similar  to  those  of  Barbadoes  aloes. 
Cape  aloes  is  reddish  brown  or  olive- 
black. 

According  to  A.  R.  L.  Dohme, 
Curagao  aloes  is  as  efficient  as  socotrine 
aloes  and  less  expensive ;  the  greater 
portion  of  the  latter  now  sold  is  made 
up  of  the  former. 

Purified  aloes  (aloe  pnrificata),  the 
form  generally  employed  in  medicine, 
is  aloes  which  has  been  softened  by 
heating  and  the  addition  of  alcohol, 
strained,  and  dried.  It  occurs  in  com- 
merce in  pieces  or  in  powder  form. 

Aloes  contains:  1.  Aloin,  a  bitter, 
crystalline  principle  present  in  amounts 
ranging  from  4  to  30  per  cent.,  and 
composed  in  socotrine  aloes  exclusively 
of  barbaloin,  to  which,  in  Curagao 
aloes,  is  added  the  isomeric  body  iso- 
barbaloin.  2.  Emodin  (Kraemer),  an 
acftively  cathartic  principle.  3.  A  yel- 
lowish, odoriferous  volatile  oil.  4.  A 
resinous  material,  varying  according  to 
the  species  of  aloes.  5.  Albuminous 
bodies.  6.  Fatty  substances.  7.  A 
small  amount  of  gallic  acid. 

Aloin,  official  as  Aloinum,  occurs  as 
minute  orange-colored  crystals  or  as 
a  microcrystalline  powder  varying  in 
color  from  lemon-yellow  to  yellowish 
brown.  It  has  little  or  no  odor,  is  bitter 
to  the  taste,  and  remains  unchanged  in 
the  air.  It  is  soluble  in  65  parts  of 
water  and  in  10.75  parts  of  alcohol.  Its 
solutions  turn  brown  on  continued  ex- 
posure, and  when  alkalies  are  added 
present  a  dark-red  color  with  greenish 
fluorescence. 

DOSE  AND  PREPARATIONS. 
■ — the  dose  of  purified  aloes  in  adults 
is  %  to  10  grains  (0.03  to  0.6  Gm.), 
the  average  dose  being  officially  given 
as  4  grains  (0.25  Gm.).  The  dose  of 
aloin  is   %   to  2  grains    (0.03  to  0.12 


Gm.).  Average  dose:  1  grain  (0.065 
Gm.).  The  other  official  preparations 
of  aloes  are  : — 

Tinctura  Aloes  (10  per  cent.),  con- 
taining also  20  per  cent,  of  licorice. 
Dose:  ^/4  to  1  fluidram  (1  to  4  c.c). 
Average  dose:  30  minims  (2  c.c). 

Tinctura  Aloes  et  Myrrhcc,  contain- 
ing aloes,  myrrh,  and  licorice,  of  each, 
10  per  cent.  Average  dose :  30  minims 
(2  c.c). 

Extractiim  Aloes. — A  watery  extract, 
dried  and  powdered.  Dose :  %  to  6 
grains  (0.03  to  0.4  Gm.).  Average  dose: 
2  grains   (0.125  Gm.). 

Piliila  Aloes,  containing  aloes  and 
soap,  of  each,  2  grains  (0.13  Gm.). 
Dose :  1  to  4  pills. 

Piliila  Aloes  et  Ferri,  containing 
purified  aloes,  dried  ferrous  sulphate, 
confection  of  rose,  and  aromatic  pow- 
der, of  each,  1  grain  (0.07  Gm.).  Dose: 
1  to  4  pills. 

Pilula  Aloes  et  Mastiches  (Lady 
Webster's  Dinner  Pill),  containing 
purified  aloes,  2  grains  (0.13  Gm.)  ; 
mastic,  %  grain  (0.04  Gm.),  and  pow- 
dered red  rose,  %  grain  (0.03  Gm.). 
Dose :  1  to  4  pills. 

Pilula  Aloes  et  Myrrhce,  containing 
purified  aloes,  2  grains  (0.13  Gm.)  ; 
myrrh,  1  grain  (0.07  Gm.),  and  aro- 
matic powder,  f^  grain  (0.04  Gm.). 
Dose  :  1  to  4  pills. 

Aloes  is  also  a  constituent  of  the 
following : — 

Tinctura  Benzoini  Composita,  con- 
taining benzoin,  10  parts;  aloes,  2; 
storax,  8 ;  tolu,  4.  Dose :  30  minims 
(2  c.c). 

Extractum  Colocynthidis  Composi- 
tnm,  containing  extract  of  colocynth, 
16  parts;  purified  aloes,  50;  resin  of 
scammony  and  powdered  soap,  of  each, 
14 ;  cardamom,  6.  Dose :  7  ]/>  grains 
(0.5  Gm.). 


568  ALOES    (SAJOUS). 

Pilula  cathartica  composita.  often  considered  preferable  because  of 

B  Ext.  colocynthidis  the  smaller  dose  required  and  less  lia- 

comp gr.  1%  (0.08  Gm.).  .                             u     ■    ■       „      j.     ■       r 

Hydrarg.    chloridi        _  bility    to    cause      griping.       It    is    fre- 

m-itis    gr.  j  (0.06  Gm.).  quently   employed   in   the   aloin,    bella- 

ResincB   jalaps    ..   gr.  %  (0.02  Gm.).  .                    j      ^       u    •           -n         r       u-  u 

CambogL  pul-  'donna,  and  strychnine  pills,  of  which 

veris    gr.  M  (0.015  Gm.).  the     official     form     {Pilula     Laxativa 

Dose:  2  pills.  Comp.)  has  already  been  referred  to. 

Pilula  cathartica  vegetahilis.  INCOMPATIBLES. — Aloes  is  in- 

IJ  Ext.  colocynthidis  compatible   with  mineral   acids,   iodine, 

comp gr.  j   (0.06  Gm.).  ..            •-      ,       .         •         -j      i         i 

Ext.  hyoscyami   .  gr.  ss  (0.03  Gm.).  silver  nitrate,  tannic  acid,  phenol,  men- 

Resince  jalapce    ..  gr.  %  (0.02  Gm.).  thol,  thymol,  and  salicylic  acid. 

RfsiJ^^fodo-'''  CONTRAINDICATIONS.  — It  is 

phylli    aa  gr.  ^  (O.OIS  Gm.).  generally  inadvisable  to  prescribe  aloes 

Olei  menthcB  •                     r   i              i     •  i             •        .■.      v 

piperitce    gr.  ^  (0.008  Gm.).  ^  cases  of  hemorrhoids,  owing  to  its 

Dose :  2  pills.  effect  of  causing  congestion  of  the  pel- 

Pilula  rhei  composita.  ^i^  organs;   in   cases   accompanied   by 

B  Rhei  puheris  ...  gr.  ij  (0.13  Gm.).  free  secretion  of  mucus  m  the  bowel. 

Aloes  gr.  iss  (0.10  Gm.).  however,  it  may,  on  the  contrary,  prove 

OlIilZnthcE'pip'.  In  i/J%-005"Gm.).  beneficial.     Aloes  is  likewise  contrain- 

Dose :  2  pills.  dicated  in  pregnancy  and  in  menorrha- 

Pilula  laxativa  composita.  gia  occurring  in  plethoric  women.     In 

IJ  Aloini    gr.  %  (0.013  Gm.).  view  of  its  elimination,  in  part,  through 

Strychnines    gr.  1/128  (0.0005  Gm.).  the  milk,  it  is  not  available  for  use  as 

Ext    h^llddoiii'icE 

fol gr.  ^  (0.008  Gm.).  a  purgative  in  nursing  women. 

Ipecacuanhce  pulv.  gr.  He  (0.004  Gm.).  PHYSIOLOGICAL      ACTION.— 

Glycyrrhisce   pulv.  gr.  ^/i  (0.046  Gm.).  _             „    .              ,                1      1    • 

In  small  doses  aloes  and  alom  exert  a 

MODES   OF  ADMINISTRA-  stomachic  Qflect.    The  secretions  of  the 

TION.— Aloes  is  entirely   soluble  in  alimentary  tract  are  augmented.     With 

5  parts  of  alcohol,  but  only  partly  sol-  larger  doses   (2  to  4  grains)    its  well- 

uble  in  water.     It  is  generally  admin-  known  laxative  effect  is  obtained,  ten 

istered  in  pill   form  on  account  of  its  to  fifteen  hours  usually  elapsing  from 

strongly   bitter   taste.      It   acts   slowly,  the  moment  of  extubation  until  the  first 

and  can,  therefore,  be  administered  at  evacuation  results.     The  effect  is  due 

bedtime  with   the   expectation   that  its  to  stimulation  of  the  muscular  coat  as 

effects  will  be  exerted  the  next  morn-  well  as  the  glands  of  the  large  intestine, 

ing.     Aloes  may  be  used  alone,  but  is  and  is  generally  attended  with  a  cer- 

oftener  given  in  conjunction  with  other  tain  amount  of  griping  pain.     Through 

cathartic   remedies   and  correctives,  as  its  property  of  inducing  hyperemia  in 

in   several   of   the   preparations   above  the  ovaries  and  uterus,  aloes  also  has 

mentioned.     Certain  agents  have  been  distinct  value  as  an  cmmcnagogue. 

found  to  increase  its  effects,  including  Though     easily     absorbed     through 

bile,  iron,  and  the  alkahes.    Equal  parts  abrasions  and  ulcerated  areas  (exercis- 

of  purified  aloes  and  dried  oxgall  may  ing  thereafter  its  characteristic  laxative 

be   administered   in   a   salol-coated   pill  and  other  effects),  aloes  exerts  no  local 

with  advantage.  Aloin,  while  somewhat  therapeutic  action.  It  is  eliminated  with 

less  certain  in  its  action  than  aloes,  is  the  feces,  slightly  with  the  urine,  and. 


ALOES    (SAJUUS). 


569 


in  nursing  women,  with  the.  mammary 
secretion. 

Aloin,  the  so-called  active  principle 
of  aloes,  is  believed  not  to  exert  its  ef- 
fect in  the  bowel  until  it  has  undergone 
certain  changes  in  composition.  The 
resulting  active  compound,  which  can 
be  made  from  the  pure,  crystalline  aloin 
by  boiling  a  solution  of  the  latter 
(Cushny),  is  probably  contained  in  the 
crude  drug  after  the  crystalline  aloin 
has  been  extracted.  Hence,  the  fact 
that  in  practice  crude  aloes  is  found 
to  act  with  greater  certainty  and  speed 
than  the  principle  aloin.  It  has  been 
found  that  in  human  beings  placed 
upon  an  exclusive  meat  diet  aloin  acts 
much  more  strongly  than  in  persons 
subsisting  on  a  mixed  diet.  The  aloin 
is  believed  to  be  altered  through  proc- 
esses of  hydrolysis  and  oxidation  into 
emodin  (oxymethylanthraquinone),  an 
active  constituent  of  many  other  drugs 
of  this  class,  such  as  senna,  cascara 
sagrada,  and  rhubarb,  which  induces 
the  purgative  effect.  Injected  under 
the  skin  or  into  a  vein,  aloin  for  the 
most  part  passes  into  the  bowel,  there 
exerting  an  irritant  effect  and  inducing 
purgation.  In  the  rabbit,  however,  in 
which  aloin  is  excreted  to  a  large  ex- 
tent through  the  kidneys,  pronounced 
irritation  of  these  organs  is  produced, 
■catharsis  being,  on  the  other  hand,  an 
infrequent  result.  A  nephritis  is  gen- 
erally induced,  in  which  the  epithelium 
of  the  tubules  is  particularly  involved, 
the  glomeruli  being  largely  spared.  The 
urine  contains  casts,  blood,  proteids, 
and  leucocytes;  it  may  be  either  aug- 
mented or  decreased  in  quantity  (Miir- 
set). 

UNTOWARD  EFFECTS.— The 
use  of  aloes  over  long  periods  is  said 
to  favor  the  production  of  hemor- 
rhoids.    Large   doses  of  aloes   induce 


burning  at  the  anus  ;  sometimes  blood- 
stained stools,  painful  micturition, 
and  uterine  discomfort.  Dosage  ex- 
ceeding 0.20  Gm.  (3  grains)  per  diem, 
when  persisted  in  for  any  length  of 
time,  leads  inevitably  to  intestinal 
irritation  and  congestion. 

According  to  Pouchet,  massive 
sing-le  doses  of  aloes  may  induce  gen- 
eral prostration  with  slowing  of  the 
pulse  and  a  fall  in  the  temperature. 

THERAPEUTIC  USES.  — As  a 
Laxative.— Aloes  is  most  frequently 
used  in  the  treatment  of  constipation 
due  to  intestinal  atony.  In  moderate 
doses  it  stimulates  the  intestinal  mu- 
cosa to  increased  secretory  activity, 
thereby  facilitating  the  discharge  of  the 
bowel  contents.  Its  continued  use  is, 
however,  to  be  avoided,  since  on  pro- 
longed administration  a  tendency  to 
aggravation  of  the  disorder  present  is 
likely  to  appear. 

A  characteristic  feature  of  the  ac- 
tion of  aloes  is  the  congestion  it  tends 
tO'  produce  in  the  intestinal  tract  (es- 
pecially the  rectum)  and  pelvic  organs. 
This  property  has  led  tO'  its  occasional 
use  as  a  derivative  in  conditions  asso- 
ciated with  cerebral  or  pulmonary  con- 
gestion, blood  being  thereby  removed 
from  the  engorged  area.  Experimental 
work  has  shown  that  aloes,  in  common 
with  other  purgatives  of  the  anthracene 
series,  does  not  act  as  a  true  chola- 
gogue,  i.e.,  does  not  increase  the  ambunt 
and  concentration  of  the  biliary  secre- 
tion. It  does,  however,  by  accelerating 
peristalsis,  promote  the  removal  of  bile 
from  the  intestinal  tract,  and  prevent 
Its  reabsorption  from  the  duodenum 
into  the  liver.  For  the  relief  of  hepatic 
congestion,  Rendu  has  recommended 
the  use  of  aloes  in  combination  with 
calomel  and  gamboge.  The  cathartic 
effect  of  aloes  has  been  found  to  be 


570 


ALOPECIA    (SCHAMBERG). 


greatly  favored  by  the  presence  of  bile, 
which  is  believed  to  assist  by  exerting 
a  solvent  action  on  the  drug,  thereby 
hastening  its  effect.  In  view  of  this 
observation,  too,  it  is  thought  that  in 
cases  of  obstructive  jaundice  the  action 
of  aloes  is  interfered  with  owing  to  the 
deficiency  of  bile. 

Alkalies  and  iron  assist  the  purgative 
action  of  aloes.  The  former  facilitate 
the  decomposition  of  aloin,  whereby  a 
more  strongly  irritant  and  cathartic 
substance  is  formed.  Iron  similarly 
favors  the  oxidation  of  aloin.  In  chlo- 
rosis the  aloes  and  iron  combination  is 
often  employed,  as  in  the  official  pill 
of  aloes  and  iron.  It  is  best,  however, 
not  to  use  this  pill,  owing  to  the  par- 
ticularly marked  constipating  effect  of 
the  preparation  of  iron  it  contains.  The 
pyrophosphate  of  iron  or  dialyzed  iron 
is  to  be  preferred.  Nux  vomica  and 
belladonna,  or  their  active  alkaloids, 
are  also  frequently  combined  with 
aloes,  the  former  to  improve  the  tone 
of  the  intestinal  muscles,  and  the  latter 
to  prevent  "griping."  The  last-named 
effect  can  also  be  minimized  by  giving 
the  drug  after  meals. 

Robin  recommends  the  following 
pill  as  a  mild,  but  efficient  laxative : — 

H  Aloes, 

Ext.  of  liquorice  ..aa  1  gr.  (0.06  Gm.). 

Gamboge ^  gr.  (0.03  Gm.) . 

Ext.  of  belladonna, 

Ext.ofhyoscyamus,3ia  1  gr.  (0.06  Gm.). 
Enough   for   1  pill.     Take  one  or  two  on 
retiring. 

Aloin  possesses  over  crude  aloes  the 
advantages  of  smaller  bulk  and  less 
tendency  to  cause  intestinal  irritation, 
but  these  are  partly  offset  by  the  dimin- 
ished certainty  and  celerity  of  its  action. 

In  large  doses  aloes  acts  as  a  drastic, 
inducing  first  eructations  and  a  feeling 
of  weight  in  the  stomach,  then  copious 
stools  with  colicky  pains.     Its  use  as 


such,  however,  is  to  be  avoided,  because 
of  the  marked  intestinal  irritation  and 
congestion  it  causes. 

As  a  Stomachic. — In  doses  not  ex- 
ceeding 1  to  1%  grains  (0.06  to  0.10 
Gm.)  daily,  aloes  improves  the  appe- 
tite and  stimulates  the  gastric  func- 
tions. 

As  an  Emmenagogue. — In  anemic 
women  with  amenorrhea  aloes  is 
sometimes  given  to  favor  the  men- 
strual flow.  It  is  best  given  four  days 
before  the  expected  period,  and  its 
action  is  greatly  enhanced  by  combi- 
nation with  iron.  In  amenorrhea  due 
to  other  causes  the  official  pill  of 
aloes  and  myrrh  may  be  tried,  the 
congestive  influence  of  the  active  drug 
tending  to  facilitate  menstruation; 
good  results,  however,  are  to  be  ex- 
pected less  frequently  than  in  the 
anemic  cases. 

In  Hemorrhoids. — Though  the  use 
of  aloes  as  a  laxative  is  contraindicated 
in  the  presence  of  hemorrhoids,  this 
drug,  given  in  small  doses,  has  been 
claimed  by  some  to  be  beneficial  in 
cases  where  the  circulation  in  the  in- 
ferior hemorrhoidal  veins  is  particu- 
larly sluggish  and  the  pile  masses 
protrude,  inducing  tenesmus.  The  use 
of  aloes  in  very  small  doses  when  hem- 
orrhoids are  associated  with  irritation 
and  frequent  small,  thin  evacuations 
has  been  advocated  by  Fordyce  Barker. 

C.  E.  DE  M.  Sajous 

AND 

L.  T.  DE  M.  Sajous, 

Philadelphia. 

ALOPECIA.— Baldness;  calvities. 

DEFINITION.  — Alopecia  is  a 
physiological  or  pathological  deficiency 
or  loss  of  hair,  either  partial  or  com- 
plete. The  forms  of  alopecia  may  be 
classified  as  follows : — 


ALOPECIA    (SCHAMBERG). 


571 


I.  Congenital  alopecia. 
II.  Senile  alopecia. 


(a)    Idiopathic. 


III. 


Premature 
alopecia. 


Hereditary  predis- 
position. 


(1)  Local  diseases. 


(&)     Symptomatic.  ^ 


(2)   General 
eases. 


Congenital  Alopecia. — This  com- 
monly manifests  itself  either  as  a  scanty 
growth,  a  development  only  in  certain 
localities,  or  as  a  retarded,  appearance 
of  the  hair.  In  rare  cases  there  may  be 
complete  absence  of  the  hair  due  to 
arrested  development  of  the  follicles. 
In  such  cases  hereditary  predisposition 
is  usually  present,  and  there  are  apt  to 
be,  in  addition,  delayed  or  defective 
dentition,  and  at  times  developmental 
defects  of  the  nails. 

[J.  H.  Hill  (Brit.  Med.  Jour.,  vol.  i,  1881, 
page  177)  has  described  a  race  of  hairless 
Australian  aborigines.    Jay  F.  Schamberg.] 

"Alopecia  congenita  familiaris,"  a 
congenital  absence  of  hair  occurring  in 
several  members  of  a  family,  observed 
in  a  brother  and  sister,  aged  respectively 
V/z  and  3H  years.  They  were  both 
born  with  hair  on  the  scalp,  but  this 
began  to  fall  out  in  a  few  weeks,  till 
the  scalps  became  perfectly  bald.    When 


dis- 


Acute 


Seborrhea. 

Eczema  seborrhoicum. 

Psoriasis. 

Erysipelas. 

Lupus  erythematosus. 

Syphilodermata. 

Folliculitis. 

Tinea  tonsurans. 

Tinea  favosa,  etc. 

Typhoid  fever. 

Variola. 

Scarlatina. 

Pregnancy. 


Syphilis. 

Leprosy. 

Myxedema. 

Neurasthenia. 

Chronic  intoxications 

Anemia. 

Diabetes. 

Cancer. 

Uric  acid  diathesis. 

Phthisis,   etc. 


Chronic  ^ 


examined  the  scalps  were  smooth, 
atrophic,  and  gloss^^  Inflammatory 
changes  were  absent.  In  both  the 
lanugo  hair  was  absent  in  the  breast 
and  extremities,  and  the  ej'elashes  were 
deficient.'  The  nails  were  not  affected 
in  either  case.  The  mother  gave  a  his- 
tory of  another  boy  in  the  family  whose 
hair  had  come  out  at  four  weeks,  and 
a  fourth  case  was  also  mentioned. 

Histological  examination  of  the  first 
2  cases  showed  the  remains  of  the 
original  lanugo  hairs  in  the  forms  of 
shrunken  hair  follicles,  in  which  the 
papillse  were  absent  and  the  inner  root- 
sheaths,  as  well  as  the  hairs,  had  dis- 
appeared. In  some  cases  the  follicles 
had  become  transformed  into  cysts  con- 
nected with  the  sebaceous  glands.  The 
parents  were  healthy  and  had  normal 
hair.  Personal  conclusion  that  the 
condition  .is  the  result  of  an  inter- 
ference with  the  normal  hair  change 
which  should  begin  in  utero.  The 
lanugo  follicles  had  undergone  regress- 
ive   changes,    and    no    permanent    hairs 


572 


ALOPECIA    (SCHAMBERG). 


had     developed.       Kraus      (Archiv     f. 
Derm.  u.   Syph.,  Aug.,   1903). 

Congenital  alopecia  may  be  divided 
into  three  classes :  1.  Complete  and 
universal  absence  of  hair  at  birth,  not 
succeeded  later  in  life  by  a  piliary 
growth.  This  is  believed  to  hz  an  intra- 
.  uterine  atrichia  due  to  a  failure  of  de- 
velopment of  the  hair-pouches.  2.  Uni- 
versal congenital  hypotrichiasis,  in 
which  at  birth  hairs  exist  in  all  regions 
of  the  body,  but  later  fail  to  be  suc- 
ceeded by  filaments  normal  in  length, 
vigor,  color,  and  texture.  Two  sub- 
varieties  of  this  condition  have  been 
recognized:  (a)  the  infant  at  birth 
is  provided  with  the  relatively  long  hair 
of  most  normal  infants;  this  in  due 
time  fails  and  is  replaced  by  a  scanty 
down,  which  later  in  life  fails  to  insure 
a  normal  hirsuteness  of  the  scalp;  (fc) 
after  birth  the  infant  fails  to  lose  the 
temporary  hair  of  the  scalp,  which  per- 
sists, but  later  develops  merely  a  scanty 
or  ill-developed  piliary  growth.  3. 
Complete  or  partial  absence  of  hair  at 
birth  in  definitely  circumscribed  regions, 
such  as  the  scalp,  the  brows,  the  pubes, 
or  the  axillae.  The  anomaly  is  rare, 
and  persistence  through  life  still  rarer. 
Many  published  observations  are  lack- 
ing in  detail  of  special  importance. 
Nevins  Hyde  (Jour,  of  Cutan.  Dis., 
Jan.,  1909). 

Senile  Alopecia. — As  the  name  indi- 
cates, this  form  of  baldness  is  observed 
in  the  aged.  With  the  atrophic  skin 
changes  that  accompany  senility  there 
takes  place  a  gradual  thinning  of  the 
hair,  beginning  upon  the  vertex  of  the 
scalp,  the  frontal  and  the  temporal 
regions,  and  slowly  leading  to  a  more 
or  less  complete  baldness  of  the  cal- 
varium.  Under  the  microscope  the 
cutis' proper  and  the  hypoderm  exhibit 
thinning  and  atrophy. 

Case  of  periodical  shedding  of  the 
hair  in  a  woman  aged  21  years.  Her 
hair  was  shed  every  winter  and  grew 
in  again  in  the  summer.  Last  winter 
she  became  entirely  bald,  and  this  sum- 
mer her  hair   did   not   grow   in   again, 


Absence  of  hair  existed  on  the  general 
surface,  which  began  in  circular  patches 
when  she  was  12  years  old.  H.  Leder- 
mann    (Jour,  of  Cut.  Dis.,  Jan.,   1904). 

Premature  Alopecia. — This  form  of 
alopecia  is  encountered  chiefly  in  in- 
dividuals between  the  ages  of  20  and 
35.  G.  T.  Elhott  found  that  among  344 
private  cases  of  premature  alopecia,  64 
per  cent,  occurred  under  the  age  of  30. 
Premature  alopecia  may  be  either  idio- 
pathic or  symptomatic. 

In  the  idiopathic  variety  the  scalp 
presents  no  abnormal  condition.  At 
first  only  a  few  hairs  fall  out  from 
time  to  time,  being  replaced  by  a  shorter 
or  finer  growth.  Later  these  fall  and 
are  followed  by  still  finer  hairs.  In  this 
manner  the  greater  part  of  the  hair  of 
the  scalp  may  be  gradually  lost.  The 
afirection  occurs  in  both  sexes,  although 
much  less  frequently  and  less  com- 
pletely in  women  than  in  men.  Heredity 
appears  to  be  a  strong  predisposing 
factor. 

There  is  a  growing  opinion  that  the 
so-called  idiopathic  baldness  is  excep- 
tional, and  that  most  cases  of  premature 
alopecia  are  associated  with  seborrhea 
in  some  form.  Of  344  private  cases  of 
premature  alopecia  studied  by  Elliott, 
316  had  seborrhea.  Jackson  found  75 
per  cent,  of  300  cases  due  to  seborrhea. 

The  symptomatic  form  results  from 
various  local  and  general  diseases. 
Rapid  falling  of  the  hair  (defluvium 
capillorum)  commonly  follows  acute 
diseases,  such  as  typhoid  fever,  small- 
pox, etc.  Full  regeneration  of  the 
hair  follows  the  restoration  to  health. 
Rapid  and  extensive  loss  of  hair 
occurs  with  frequency  in  the  early 
stages  of  syphilis.  The  hair  is  also 
thinned  or  lost  in  such  cachectic  condi- 
tions as  phthisis,  myxedema,  di-abetes 
mellitus,  leprosy,  etc. 


ALOPECIA    (SCHAMBERG). 


573 


Areas  of  absolute  alopecia  which  oc- 
cur iu  the  scalp  or  beard  in  sj-philis 
may  be  small  and  few,  well  circum- 
scribed, lasting  a  short  time,  but  recur- 
ring often.  This  is  very  different  from 
the  general  thinning  of  the  hair  seen 
early  in  the  disease,  which  never  re- 
turns. A.  Fournicr  (Jour,  des  Prati- 
ciens,  Jan.  19,  1901). 

Alopecia  is  not  a  common  or  regular 
symptom  of  the  early  stages  of  syphilis. 
The   slight   loss   of  hair  which   is   con- 
stantly taking  place  in  healthy  individ- 
uals as  the   result  of  the   physiological 
change   in  the  hair  continues  its  exist- 
ence through  and  beyond  the  course  of 
S3'philis,   and   must   be   taken   into   con- 
sideration before  attributing  to  syphilis 
a  loss  of  hair  so  slight  as  to  pass  un- 
noted   or   scarcely   attract  the   patient's 
attention.      Klotz    (Jour,    of    Cut.    Dis., 
Mar.,   1907). 
Alopecia  Seborrhceica.  —  Consider- 
able difterence  of  opinion  exists  as  to 
what  constitutes  the  seborrheic  proc- 
ess ;  the  comprehension  of  the  relation 
of   seborrhea  to  baldness   is   thereby 
embarrassed.     Nearly  all  writers  are 
agreed  that  dandruff  has  not  the  same 
sig^nificance  for  all  observers.   Sabour- 
aud    holds    that    dry   pityriasis    of    the 
scalp     is     not     a     depilating    affection 
itself,  but  that  it  is  frequently  asso- 
ciated with  the  true  seborrhea.   Many 
clinicians  speak  of  an  alopecia  pityrodes 
in  which  there  is  either  a   seborrhea 
with  fatty  crusts  or  a  pityriasis  with 
abundant  scaling.     Crocker  does  not 
restrict    alopecia    seborrhceica    to    the 
oily  form  :  according  to  his  experience 
there  is   either  "an   excessive  greasi- 
ness  of  the  surface  from  oily  sebor- 
rhea,    or     fine,     glistening,     powdery 
scales,  or  greas}-  scales  lying  closely 
on    the    scalp    and    requiring    to    be 
scraped  ofif,  or  yellowish,  fatty  matter 
looking  like  pale-yellow  wax." 

New  clinical  form  of  atrophic  alo- 
pecia, for  which  the  term  "pseudo- 
pelade"  is  adopted.     It  is  a  process  of 


atrophy  and  sclerosis  affecting  the  hair- 
covered  regions  of  the  body,  especially 
the  scalp,  terminating  in  patches  of 
baldness,  smooth,  of  pseudocicatricial 
aspect.  It  seems  to  be  closely  allied  to 
erythematous  lupus  and  keratosis  pilaris. 
Brocq,  Lenglet,  and  Ayrignac  (Annales 
de  dermat.,  vol.  i,  No.  3,  1905). 

Analysis  of  679  cases  of  loss  of  hair, 
chiefly  alopecia  simplex  and  alopecia 
furfuracea.  There  were,  however,  86 
cases  of  alopecia  and  lesser  numbers 
due  to  ringworm  and  syphilis,  and  2 
cases  from  X-rays.  Women  seemed  to 
be  more  affected  by  loss  of  hair,  in  the 
relative  proportion  of  54  to  46,  but 
possibly  they  consult  physicians  more 
freely  on  this  account  than  do  men. 
The  author  finds  that  heredity,  dan- 
druff, systemic  depression,  fever,  opera- 
tions and  maltreatment  of  the  scalp 
have  been  connected  in  the  patients' 
minds  with  the  fall  of  hair  and,  accord- 
ing to  his  figures,  hereditary  taint  ex- 
ists in  30  per  cent,  while  dandruff  was 
present  in  443  patients,  a  percentage 
of  more  than  79.  Systemic  depression 
was  recorded  in  120  cases,  fever  in  63, 
and  maltreatment  was  evident  in  277 
cases,  or  nearly  half  of  the  whole  num- 
ber. Most  patients  were  unable  to  re- 
member the  date  of  beginning  alopecia, 
but  it  seems,  with  all  the  accurate 
data  that  could  be  obtained,  that  in  the 
clinically  imcomplicated  loss  of  hair, 
it  began  before  30  in  84  per  cent,  of 
the  males.  In  females  it  appeared  at 
this  early  age  in  a  much  less  percentage 
and  seemed  to  be  of  later  development. 
Dandruff  appeared  also  earlier  in  men 
than  in  women,  being  about  twice  as 
frequent  between  the  ages  of  16  and 
25.  C.  J.  White  (Jour.  Amer.  Med. 
Assoc,  Sept.  24,  1910). 

ETIOLOGY  AND  PATHOLOGY. 

— Dandruff  is  generally  regarded  as 
the  most  potent  cause  of  baldness.  It 
is  a  plausible  and  attractive  theory 
to  attribute  the  process  to  microbic 
invasion.  Sabouraud  has  brought 
forth  strong  evidence  to  show  that 
his  microbacillus  is  intimately  asso- 
ciated with,  if  not  the  cause  of,  oily 


574 


ALOPECIA    (SCHAMBERG). 


seborrhea.  He  likewise  regards  this 
org-anism  as  the  cause  of  baldness. 
The  microbacillus,  according  to  him, 
enters  the  mouth  of  the  hair  follicle, 
multiplies,  and  forms  a  thin  microbic 
lamina,  which  separates  the  hair  shaft 
from  the  follicular  wall.  Epithelial 
irritation  causes  the  encysting"  of  the 
bacilli   in   a   plug   or   cocoon.     Then 


Alopecia  from  a  cured  tinea  favosa.    (Schamberg. ) 

follows  increased  sebaceous  flow, 
hypertrophy  of  the  sebaceous  gland, 
and  progressive  atrophy  ol  the  hair 
papillae.  Sabouraud  recognizes  other 
causes  which  render  the  soil  favor- 
able, such  as  city  life,  insufficient 
exercise,  excessive  meat  diet,  gout, 
heredity,  etc.  If  baldness  has  a  mi- 
crobic origin,  Sabouraud  is  certainly 
correct  in  regarding  the  above  causes — 
causes  which  are  operative  in  the  busy 
life  of  great  cities — as  of  vast  impor- 
tance. Premature  baldness  is  rare  or 
absent  among  savages  and  is  less  com- 
mon in  country  than  in  city  districts. 


Many  other  factors  have  been  in- 
voked .  as  causes  of  baldness,  such  as 
the  too  frequent  wetting  of  the  hair, 
the  wearing  of  stiff  hats  which  con- 
strict the  temporal  arteries,  etc.  It  is 
also  stated  that  brain  workers  are 
particularly  subject  to  premature  alo- 
pecia ;  this  is  probably  more  the  result 
of  sedentary  life  than  of  intellectual 
activity. 

The  skin  of  the  scalp  overlying  the 
epicranial  aponeurosis  has  no  under- 
lying muscles  to  exercise  it,  and  has 
onl}'-  the  action  of  the  occipitofrontalis 
to  depend  on,  and  moves  only  when 
that  muscle  is  put  into  action.  That  is 
not  often.  The  scalp  is  very  vascular ; 
there  is  nothing  to  interfere  with  or 
retard  the  arterial  supply,  but  there  is 
also  nothing  to  accelerate  the  return 
flow — no  active  muscular  exercise  in  the 
part  whatever  to  hurry  along  the  waste 
products  and  the  deoxygenized  blood  in 
the  vessels.  These  structures  being  su- 
perficial and  easily  compressible,  their 
compression  by  the  rim  of  the  hat  will 
further  retard  the  flow.  In  women  the 
scalp  is  well  exercised  by  the  combing, 
plaiting,  and  throwing  from  side  to  side 
of  the  hair — men  scarcely  give  more 
than  a  moment  to  the  brushing  and 
combing  of  their  hair.  Massage  is  the 
treatment  to  be  applied,  especially  as  a 
preventive.  George  Elliott  (Dominion 
Med.   Monthly,   Mar.,   1902). 

Alopecia  areata  is  often  caused  by 
traumatisms  of  the  head.  The  exist- 
ence of  anatomical  and  functional 
lesions  of  the  central  nervous  system 
must  be  admitted,  the  state  of  central 
irritation  giving  rise  to  peripheral 
trophic  disturbances,  which  manifest 
themselves  by  the  appearance  of  hy- 
peralgesic  zones.  Possibly,  vascular 
lesions  analogous  with  arteriosclerosis 
are  the  cause  of  the  falling  out  of  the 
hair.  At  any  rate,  the  nervous  lesion 
is  the  predominant  etiological  factor. 
Psychic  traumatism,  especially  fright, 
has  an  identical  effect.  Weichselmann 
(Deut.  med.  Woch.,  Nov.  12,  1908). 

Alopecia  of  dental  origin  often  fol- 
lows   a    painful    attack    of    trigeminal 


ALOPECIA    (SCHAMBERG).  575 

neuralgia  caused  by  the  teeth  (18  out  the  scalp  to  s.unlight,  the  restricted 
of  25  cases).  This  attack  may  pre-  ^gg  ^f  j^g^^s  (Sabouraud  says  bald- 
cede    the    depilation    by    two    or    three  .     ,                              .                "      .        . 

,,      ,    ^                          ,     V  ness  IS  less  common  m  ves"etanans), 

months,   but   more   commonly  it  occurs  ==                  ^ ' 

in  the  preceding  month.     It  occurs  on  the  avoidance  of  excesses  of  all  kinds, 

the  same  side  as  the  trigeminal  attack,  are  to  be  recommended, 

more   frequently   on   the   left   side   be-  Such     tonics     as     iron,     Strychnine, 

cause  dental  lesions  are  more  common  phosphorus,  arsenic,  and  codliver  oil 

on  the   left  side.     It  appears   bv  pref-  .         ,,      ,                    .,      ,        .  , 

J.          ,     '  may  occasionally  be  prescribed  with 

erence  m  certam  predisposed  zones,  as  -'                           -            ^ 

if    there    was    a    relation    between    the  advantage. 

seat  of   the   dental    irritation   and   the  Local   treatment   is   of   great   impor- 

seat    of   the    initial    area    of    alopecia,  tance,    particularly    when    dandruff    is 

■   Thus,  in   16  cases  of  trouble  with  the  present.       It    consists    of    the    proper 

lower  wisdom  tooth  the  author   found  ,          .           -    ,             ,            ,     ,          .       , 

,        •     1      T     1  „     4.U     o o  c.;^^  r.(  cleansing  of  the  scalp  and  the  stimula- 

alopccia  localized  on  the  same  side  oi  _              °                         >- 

the  nucha  in   14.     It   follows  alveolar  tion  of  the  sebaceous  glands  to  healthy 

and  gingival  irritation  rather  than  den-  action. 

tal  irritation  proper.    Thus,  in  25  cases  The  tincture  of  green  soap  makes  an 

of    dental    alopecia   the    author   traced  admirable  shampoo  for  the  removal  of 

the  cause  m  3  cases  to  inflammation  of  .  ,     ,.                                         ,  ,    .         rr.    . 

the  dental  pulp,  in  the  remaining  22  to  epithehal  and   sebaceous   debris.     This 

troubles  outside  the  teeth.     These  irri-  may    be    advantageously     followed    by 

tations  seem  to  act  differently  upon  the  such  a  hair- wash  as : — 

trigeminus.     It  is  accompanied  by  cer-  ^  Resorcinolis 3ij    (8  Gm.). 

tain  phenomena,  such  as  hyperesthesia,  Acidi  acetici  ...    f3j-f3ij    (4-8  c.c). 

erythrosis,     hyperthermia,     adenopathy,  Ql.  ricini' fSss-fSj   (2-4  c.c). 

lymphangeitis,    and  edema,   grouped  by  Alcoholis,  q.  s.  ad  fHvj   (180  c.c). 

Jacquet  under  the  name  of  the   dental  Ql.   bergamott...    n^xl  (2.4  c.c). 

syndrome.      The    areas     are    generally  T^n                  ^         j-       i   .•        ■■,•■, 

1,  .      .          1  r       •           1,        rru  When  greater  stimulation  is  desired, 

small  m  size  and  few  in  number,     ihe  °                                                           ' 

prognosis  is  good.     The  cure  is  rapid  ^he  following  lotion  may  be  used  :— 

and    often    immediate    after    dental    in-  ^  Hydrarg.    chlor. 

tervention       alone.        Rousseau-Decelle  corros gr.  viij    (0.5   Gm.). 

(Presse  med.,  Feb.  6,  1909).  BetanaphthoUs   .  gr.  xxv    (1.6    Gm.). 

PROGNOSIS.  — Alopecia      sebor-  GJycerini   fSj  (4  c.c). 

,      .  ,      „  ^  ,  Alcohohs   fgiv  (120  c.c). 

rhoeica     gradually     progresses,     unless  ^^^     ^^;^^^^.. 

checked  by  treatment,  to  a  denudation  gnsis   fHss  (15  c.c). 

of  the  vertex  leaving  a  fringe  of  hair  Aqucs    fSiiss   (75  c.c). 

in  the  temporal  and  occipital  regions.  Sig. :    Hair-wash ;  part  the  hair  and  apply 

Appropriate  treatment,  particularly  if  ^^*^  ^  '"^^^^  ^P°"S^- 

instituted  early,  will  sometimes  check  Another  lotion  frequently  prescribed 

the  hair  loss  and  lead  perhaps  to  some  ^^^^^re    stimulation    is    desired    is    as 

regrowth.     If   systemic  conditions  are  lollows : 

present  which  render  the  scalp  a  favor-  ^  Tmct.     canthar- 

able    nidus,    the    outlook    is    more    un-  rJ-  ^^,          "•'.■'■      ^^         ^ 

1  met.    capsici, 

favorable.  Olei  rkini  ....aa  ni.xxx-f3j    (2-4  cc). 

TREATMENT.  —  The     treatment  Spts.  myrcice  (bay 

must  be  directed   toward   the   existing  rum),  q.  s.  ad  f5vj  (180  c.c). 

seborrheic  process.     The  measures  em-  It  is  a  good  plan  in  many  cases  to  use 

ployed  relate  both  to  general  and  local  an  ointment  in   conjunction   with   hair 

treatment.     Outdoor  life,  exposure  of  lotions.     The  lotion  may  be  used  each 


576  ALOPECIA    (SCHAMBERG). 

day,   and   the   pomade   applied   once   or  nally,   an   ointment   is   applied   contain- 
twice    a   week.      The   latter    should   be  "^^  ^  P^^t  of  salicylic  acid,  2  of  tinc- 
,  ,      ,  .     .                       11              ■■  ture  of  benzoin,  and  50  of  vaselin.    In 
rubbed  m  m  very  small  quantities,  so  as  u  .■     .             \.t.     ^      .        .  ■     -u 

■'  ^  '  obstinate  cases  the  treatment  is  be- 
to  avoid  disagreeable  greasing  of  the  gun  by  the  application  of  tar  liniment, 
hair.  When  ointments  are  used  con-  which  is  removed  ten  minutes  later 
jointly  with  washes,  the  glycerin  or  with  the  soap.  Lassar  CDeut.  med. 
oil  in  the  lotion  may  sometimes  be  ad-  Woch.,  July  5,  1906). 
vantageously  omitted.  Sulphur  is  the  The  most  satisfactory  lubricant  is 
,1  ,  ,  1  1  cocoanut  oil.  It  keeps  the  hair  soft 
most  useful   agent  for  scalp  pomades  ,    ...          ,    ,         ^^       .  .i.    i    • 

°                            ^    ^  ana  silky  and  does   not  mat  the  hair 

when   any   seborrhea   is  present.  ^  The  ^^  pj^g^^^  j^  ^^^^^_    ^  ^^^^  shampoo 

following  ointment  gives  most  satisfac-  about    once    a    month    suffices.      The 

torv  results  :- —  wire    brush    keeps    the    scalp    pretty 

i  Sulph.  prcEcip 3j  (4Gm.).  ^^^^  ^^°"^   ^^^t  ^"^  dandruff.     By  its 

Adipis    Bj  (31  Cm.-) .  ^^"tle   a-nd   not    disagreeable   friction 

01.  bergamott  ^xl  (2.4  c.c).  °^  ^he  scalp,  it  promotes  the  circula- 

tion   and  thus  brings  nourishment  to 

Daily  digital  massage  of  the  scalp  the  hair-bulbs,  and  gives  vigor  to  the 

is  distinctly  useful,  as  is  also  the  vig-  growing  hair.     S.  Hendrickson  (Jour. 

orous  use  of  the  hairbrush  to  produce  ^^"^e''-  ^^^-  ^^s°^-'  Sept.  2,  1911). 

hyperemia  of  the  scalp.  The  frequency  with  which  the  scalp 

Successful    treatment    depends    upon  should  be  washed  depends  entirely  upon 

the    promptness    with    which    one    first  the  degree  of  oiliness  of  the  SCalp  and 

notices   that  the  hair  is  beginning  to  j^^ir.    A  greasy  scalp  requires  more  fre- 

fall.     Healthy  hairs   do  not  come  out,  ^1-^1               1                     t 

,  .,  ,    .             ,       ,          ,        .„  quent  cleansing  than  a  dry  one.     In  a 

and  if  hairs  are   found  on  the  pillow,  .                         -^  . 

on  the  clothing,  or  in  the  hairbrush,  the  general   way   it  may  be    said   that   the 

indication    is    given    for   beginning  the  scalp   should  be  washed  about  once  in 

treatment.     One  of  the  most  important,  two  or  three  weeks.     If  the  skin  is  very 

yet  very  generally  neglected,  prophylac-  ^j-y    afterward,    a    pomade     should    be 

tic  measures  consists  in  frequent  ablu-  110                    .    •    •             11 

J.    ,      ,      J                         1       .  emploved.     Soaps  containing  sulphur 

tion  of  the  head,   a  measure  that   is  ^     -                    ^                         »         r 

still    considered    injurious    by    many  ^^^  tar  are  useful.     Some  of  the  Ger- 

people.     On   the   contrary,   frequent  man  superfatted  soaps,  especially  one 

shampooing  and  rubbing  of  the  head  containing  sulphur,  salicylic  acid,  and 

is   the   best   preventive    of   baldness,  resorcin,  are  particularly  eligible  for 

Another  feature  on  which  the  author  ., 

1              u    .         •    ..1,               -^    r  the  purpose. 

lays  much  stress  is  the  necessity  for 

cleanliness  in  all  utensils  used  in  the  Several  cases  of  very  severe  alopecia 

barber  shop  or  in  private.  i"    which    the    employment    of    static 

Actual  baldness  cannot  be  cured,  but  electricity  had  given  the  best  results. 

a  great  deal  can  be  done  to  prevent  its  I"  4  cases  this  mode  of  treatment  was 

onset  by  properly  treating  the  tendency  successful;     in     1     unsuccessful.       The 

to    falling   of  the   hair.      A    course    of  successful  cases  were  all  cured,  and  this 

treatment  is  outlined,  of  which  the  fol-  after    about    twenty    or    thirty    sittings, 

lowing  are  the  most  important  features :  The  patients  were  submitted  to  the  elec- 

Daily  shampooing  with  soap  and  hot  trie  bath,  and   sparks  were   discharged 

water,  followed  by  drying  and  the  ap-  on    the    smooth,    hairless    patches.      R. 

plication  of  a  1 :  1000  solution   of  bi-  Pivani    and   J.    Blasi    (Annali    di    Elet. 

chloride  of  mercury.    This  is  allowed  Medica  e  Terapia,  Apr.,  1902). 

to    evaporate,    and   the   scalp   is   then  The  high-frequency  spark  employed 

rubbed    with     a     1 :  400     solution     of  in  a  lady,  aged  30  years,  who  had  some 

thymol   or  naphthol  in   alcohol.     Fi-  early  osteoarthritic  changes  in  the  small 


ALOPECIA    AREATA    (SCHAMBERG). 


577 


joints  of  the  hand  and  came  to  the 
writer  complaining  of  slight  schorrheic 
rash  on  the  face  and  considerable  thin- 
ning and  falling  of  hair.  The  results 
were  brilliant.  A  thick  growth  of  hair 
of  good  quality  ensued,  but  the  same 
application  failed  afterward  in  appar- 
ently similar  conditions.  David  Walsh 
(Lancet,  June  15,  1907). 

The  drugs  most  successful  in  treating 
loss  of  hair  are  euresol,  bichloride  of 
mercury,  captol  and  chloral  hydrate. 
The  final  results  of  treatment  are  al- 
most disheartening,  but  from  a  tem- 
porary point  of  view  we  may  expect 
good  or  very  good  response  in  48  per 
cent,  of  men  and  in  56  per  cent,  of 
women.  C.  J.  White  (Jour.  Amer. 
Med.  Assoc,  Sept.  24,  1910). 

Jay  F.  Schamberg, 

Philadelphia. 

ALOPECIA  AREATA.- Alope 
cia  circumscripta;  area  celsi. 

DEFINITION.— Alopecia  areata 
is  a  disease  of  the  hairy  system  char- 
acterized by  the  more  or  les's  sudden 
occurrence  of  round  or  oval  circum- 
scribed bald  patches,  in  rare  cases 
coalescing  and  producing  total  bald- 
ness. 

SYMPTOMS.  — The  disease  is 
usually  limited  to  the  scalp.  The 
patches  are  circumscribed  and  round, 
and  vary  in  size  from  a  coin  to  the 
palm  of  the  hand.  The  skin  is 
smooth,  soft,  of  a  dead-white  color, 
and  totally  devoid  of  hair.  Occasion- 
ally the  patches  are  pinkish  as  a 
result  of  slight  hyperemia.  The  fol- 
licular openings  are  contracted  and 
less  prominent  than  in  the  healthy 
scalp. 

To  the  feel  the  skin  is  thin,  soft, 
and  pliable.  In  the  beginning,  the 
patches  are  level  or  slightly  ele- 
vated, while  later  they  are  sometimes 
slightly  depressed. 

The   course   of   the   disease   is   ex- 


tremely variable.  In  some  cases  the 
bald  patches  develop  suddenly  in  the 
course  of  a  few  hours.  '  In  other 
cases,  the  hair  loss  is  gradual,  extend- 
ing over  a  period  of  a  few  days  or 
weeks.  The  areas  then  spread  by 
peripheral  extension  until  they  reach 
a  certain  size,  when  they  remain  sta- 
tionary. 


Alopecia  totalis  following  an  ordinary  alopecia 
areata.    (.Schamberg.) 


In  some  cases  the  entire  scalp 
becomes  denuded  of  hair,  giving  to 
the  patient  a  most  grotesque  appear- 
ance. In  extensive  cases  it  is  by  no 
means  rare  for  the  eyebrows  and  eye- 
lashes to  be  lost.  In  men  the  bearded 
region  of  the  face  may  be  involved, 
either  alone  or  in  conjunction  with 
the  scalp. 

The  duration  of  the  disease  varies 
greatly.  Recovery  seldom  occurs  in 
less  than  a  few  months,  while  many 
cases  last  several  years.    The  disease 


1—37 


578 


A.LOPECIA   AREATA    (SCHAMBERG). 


may  occur  at  any  period  of  life.  In 
young-  individuals  the  hair  usually 
returns  sooner  or  later.  In  adults, 
the  baldness  may  persist  and  prove 
refractory  to  all  treatment. 

When  regrowth  occurs,  the  patch 
is  first  covered  by  fine,  downy,  whitish 
hairs  which  are  either  shed  or  later 
converted  into  coarse  and  pigmented 


Alopecia  areata.    (Schatnherg, ) 

hairs.  Not  infrequently  the  hair 
grows  in  and  the  patient  thinks  he  is 
on  the  road  to  recovery,  only  to  have 
his  hopes  shattered  by  the  hair  falling 
out  again.  As  a  rule,  there  are  no  sub- 
jective symptoms. 

Alopecia  areata  occurs  with  similar 
frequency  in  the  two  sexes.  It  is 
more  common  in  youth  and  early 
adult  life  than  in  other  age  periods. 
Crocker  states  that,  of  506  hospital 
cases,  214  were  under  15  years  of  age, 
and  214  occurred  in  persons  between 
the  age  of  15  and  35. 


Case  in  a  well-developed  girl,  4  years 
of   age,   whose   general   health   had   al- 
ways been  good.     She  is  said  to  have 
had    fairly   thick   blond    hair   until   two 
years  ago,  when  small  bald  patches  be- 
gan to  appear.     These  rapidly  increased 
in  size,   and  soon  the  case  became  one 
of    the    so-called    malignant    type.     At 
present  practically  all  of  the  scalp  hair 
has    been    lost,    as    well     as    the    eye- 
brows   and    lashes.      Kingsbury     (Jour, 
of  Cutan.  Dis.,  July,  1909). 
ETIOLOGY.— They   are   two   dis- 
tinct   theories    of    the    causation    of 
alopecia   areata.      One    school    insists 
that  the  disease  is  parasitic,  and  cites 
occurrences    of   epidemics    in   institu- 
tions   as    proof    of    this    view.      Epi- 
demics  have   been   observed   chiefly  in 
France    and    Germany :     Bowen    and 
Putnam    describe    an    outbreak    in    an 
institution  in  this  country. 

The  bacteriological  theory  of  alopecia 
areata  still  requires  confirmation,  none 
of  the  organisms  at  present  found  hav- 
ing justified  a  claim  to  be  regarded  as 
the  specific  cause.  On  the  other  hand 
there  is  evidence  of  contagiosity  and 
infectiousness.  As  regards  the  fre- 
quency of  the  affection,  it  would  appear 
that  this  is  on  the  increase.  Caution 
must,  however,  be  used  in  assuming 
this  increase  to  be  actual.  The  greater 
frequency  with  which  people  now  con- 
sult specialists,  and  the  consequently 
greater  accuracy  of  diagnosis,  may  give 
rise  to  fallacies  in  this  direction.  It 
represents  1.4  per  cent,  of  all  -cases 
treated  by  the  writer.  The  chief  age 
incidence  lies  between  20  and  30,  and 
the  sexes  are  affected  in  the  proportion 
of  about  7  males  to  3  females.  O. 
Lassar  (Dermat.  Zeit.,  Sept.,  1900).  • 
Among  30  cases  observed  within  a 
brief  period  by  the  writer,  there  were 
no  instances  in  which  contagion  could 
be  traced.  He  does  not  think  that  the 
existence  of  this  disease  in  epidemic 
form  has  been  proved,  notwithstanding 
that  instances  in  which  it  occurs  in 
barracks  are  well  known.  This  fact 
may  be  explained  in  other  ways.  M. 
Cruyl  (La  Clinique,  Apr.  27,  190]). 


Alopecia  areata  (schamberg). 


579 


The  cause  of  alopecia  areata  is  not 
an  infection,  but  some  neurotrophic  in- 
fluenie.  Division  of  the  second  cra- 
nial nerve  experimentally  causes  it; 
besides,  thallium  acetate  applications 
cause  neurotrophic  affections  of  the 
entire  body.  And  with  atrophy  of  the 
fibers  of  the  sympathetic  nerves  in  cer- 
tain regions  alopecia  results,  especially 
when  the  trigeminus  is  afifected.  From 
his  observations  the  writer  believes  alo- 
pecia areata  always  to  be  neurotrophic 
in  character.  E.  Richter  (Berl.  klin. 
Woch.,  Dec.  29,  1902). 

Giovanni  observed  that  patients  to 
whom  he  was  administering  acetate  of 
thallium  became  affected  with  alopecia. 
The  writer  studied  the  effect  of  small 
doses  of  this  drug  on  mice,  given  in 
food.  The  result  of  its  administration 
was  that  the  hair  came  out  on  different 
parts  of  the  body.  This  effect  was  not 
due  to  any  appreciable  local  action  of 
the  drug  on  the  skin,  but  in  the  writer's 
opinion  to  certain  disturbances  affect- 
ing the  peripheral  nervous  system  of  a 
trophic  nature.  Buschke  (Berl.  klin. 
Woch.,  Nu.  53,  1900). 

Alopecia  areata  is  trophoneurotic  in 
origin,  as  first  urged  by  Jacquet,  who 
noted  some  close  relation  between  alo- 
pecia and  dental  neuralgia.  His  investi- 
gations show  that  neuralgia  occurs  be- 
fore, with,  or  after  the  alopecia,  in  al- 
most all  cases.  This  dental  theory  of 
the  origin  of  alopecia  is  confirmed  by 
a  case-history  which  the  writer  quotes, 
a  child  in  whom  the  condition  disap- 
peared after  the  affected  gum  had  been 
cauterized.  F.  Tremolieres  (Presse 
med.,  June  14,  1902). 

Case  of  alopecia  areata  affecting  man 
and  wife.  In  the  man  alopecia,  vitiligo, 
and  blanching  of  the  hair  and  beard 
occurred  almost  at  the  same  time  after 
emotional  trouble  in  a  patient  of  a 
neuroarthritic  diathesis.  The  wife,  also 
a  neuroarthritic  subject,  suffered  from 
the  same  emotional  cause,  and  had  loss 
of  hair  and  eyebrows.  In  these  cases 
the  cause  appears  to  be  trophoneurotic. 
In  the  male  the  patches  were  typical 
of  alopecia  areata ;  in  the  female,  irreg- 
ular and  disseminated.  Levy  (Jour,  des 
tnal.  cut.  et  syph.,  May,  1902). 


Recalling  Jacquet's  theory  that  bald- 
ness is  of  nervous  origin,  and  is  con- 
nected with  skin  diseases,  dental  trou- 
bles, and  crises  of  gastrointestinal  and 
other  origin,  the  writer  refers  to  a 
case  in  which  the  cure  of  a  fistula  in 
ano,  complicated  with  entire  loss  of 
hair,  was  succeeded  by  complete  res- 
toration of  eyelids,  eyebrows,  and  hair 
of  the  scalp.  Eyraud  (Presse  med., 
Mar.  30,   1904). 

On  the  other  hand,  there  is  irrefu- 
table clinical  evidence  of  the  neuro- 
pathic origin  of  cases  of  alopecia 
areata.  Nervous  shock,  such  as 
fright,  prolonged  anxiety,  etc.,  and 
traumatism  to  the  scalp  have  been 
directly  followed  by  areate  loss  of 
hair. 

[I  recently  saw  a  boy  admitted  to  the 
Polyclinic  Hospital  for  the  fracture  of  the 
skull  who  developed  alopecia  areata  before 
leaving  the  institution.  Max  Joseph  has 
produced  the  disease  in  cats  by  excision 
of  the  second  cervical  ganglion.    J.  F.  S.] 

It  v^ould,  therefore,  appear  that 
there  are  two  varieties  of  alopecia 
areata,  the  one  parasitic  and  the 
other  trophoneurotic.  In  the  epidemic 
observed  by  Bowen  and  Putnam,  the 
patches  were  not  identical  with  those 
commonly  observed,  but  were  smaller 
and  more  irregular  in  shape.  Some 
of  the  English  dermatologists  are  of 
the  opinion  that  alopecia  areata  is 
prone  to  occur  in  those  who  have  at 
some  previous  period  suffered  from 
ringworm  of  the  scalp.  Sabouraud 
regards  his  microbacillus  as  the  prob- 
able cause  of  alopecia  areata,  though 
the  influence  of  syphilis  is  not  over- 
looked by  him. 

Extensive  alopecia  due  to  syphilis, 
either  acquired  or  hereditary,  oftener 
than  to  any  other  single  cause,  as 
suggested  by  the  success  obtained 
with  antisyphilitic  remedies.  Sabour- 
aud (Ann.  de  derm,  et  de  syph.,  p. 
545,  1910). 


Alopecia  areata  (schamberg). 


Study  of  14  typical  cases  of  alopecia 
areata.  In  11  of  these  the  writer  ob- 
tained a  positive  Wassermann  re- 
action, when  there  were  no  symptoms 
of  syphilis,  either  hereditary  or  ac- 
quired. The  3  negative  cases  were 
the  subjects  of  single  alopecic  patches 
which  were  speedily  cured  by  local 
stimulation.  Du  Bois  (Ann.  de  derm, 
et  de  syph.,  Nov.,  1910). 

PATHOLOGY.  —  Both  Giovanni 
and  Robinson  found  evidences  of  in- 
flammatory disturbances,  chiefly  in 
subpapillary  layer.  Perivascular  cell 
infiltration  was  observed  in  both 
■early  and  late  lesions.  Subsequently 
atrophic  changes  take  place  with 
destruction  of  the  hair  papillse. 

The  characteristic  hair  of  alopecia 
areata  has  the  shape  of  an  exclamation 
point.  The  upper  part  is  pigmented 
and  normal,  while  the  lower  portion 
is  atrophied  and  without  pigment. 
Sabouraud  describes  an  ampullar  swell- 
ing (the  peladic  utricle)  filled  with 
the  microbacillus  in  the  upper  third 
of  the  hair  follicle. 

.    Alopecia  Areata. 

1.  Rapid  onset. 

2.  Patches  are  : — 

(o)  Totally  devoid  of  hair. 

(&)  Pale  or  whitish  in  color, 

(c)  Smooth  or  soft, 

(c?)  Follicles  contracted. 

3.  Absence  of  fungus. 

4.  Common  in  adolescence  and  adult  life. 

The  baldness  of  early  syphilis  may 
bear  some  resemblance  to  alopecia 
areata.  Apart  from  the  presence  of 
other  evidences  of  the  disease,  the 
patches  are  moth-eaten  in  appearance 
and  not  sharply  circumscribed.  The 
surrounding  hair  and  scalp  are  luster- 
less  and  dirty,  whereas  in  alopecia  are- 
ata they  are  perfectly  normal. 

PROGNOSIS.— In  children  recov- 
ery   usually    takes    place.      In    young 


adults  the  prognosis  is  usually  favor- 
able, while  in  advanced  adults  it  is  un- 
favorable. The  longer  the  disease  has 
persisted,  the  more  unfavorable  is  the 
prognosis.  The  duration  of  the  disease 
is  uncertain  and  relapses  are  not  un- 
common. 

TREATMENT.— The  internal  treat- 
ment consists  of  the  use  of  such  tonics 
as  iron,  strychnine,  quinine,  codliver 
oil,  phosphorus,  and  arsenic.  Duhring 
considers  arsenic  to  be  "especially  ser- 
viceable." 

The  local  treatment  has  for  its  pur- 
pose the  stimulation  and  rubefaction  of 
the  scalp  with  the  object  of  increasing 
the  blood-supply  to  the  follicles.  Many 
cases  terminate  in  spontaneous  recov- 
ery^ and  conservative  judgment  is  de- 
sirable in  interpreting  the  value  of 
remedies  employed.  Among  the  many 
medicaments  which  have  been  advised 
are  alcohol,  cantharides,  capsicum,  the 
essential  oils,  turpentine,  carbolic 
acid,     trikresol,     ammonia,     sulphur, 

Ringworm. 

1.  Slow,  insidious  onset. 

2.  Patches  are  : — 

(a)   Covered  with  broken-off  stumps, 
(fo)   More  or  less  reddened, 
(c)  Rough  and  scaly. 
{d)   Follicles  prominent;    "goose-flesh" 
appearance. 

3.  Trichophyton  fungus  present. 

4.  Occurs  almost  exclusively  in  childhood. 

iodine,  mercury,  chrysarobin,  beta- 
naphthol,  etc. 

The  following  lotion  will  be  found 
of  value : — 

R  Tinct.  cantharides^ 

Tinct.  capsici,  of  each  fHiss   (6.00  c.c). 

01   ricini    fSij    (8.00  c.c.) . 

Aquce   cologniensis    .   f§j  (30.00  c.c). 
Sig. :     Brush  in  vigorously  each  day. 

Instead  of  lotions,  ointments  such  as 
the  following  may  be  employed: — 


ALOPECIA    AREATA    (SCHAMBERG). 


58i 


B  Bctanaphthol   3j    (4.00  Gni.). 

J-aselini 5j    (31.00  Cm.). 

01.  bcrgamott ni.xl   (2.46  c.c). 

Sig. :     Rub  in  twice  a  day. 

An  efficient  treatment  consists  in  the 

swabbing   of    the   bald   areas   once    or 

twice  a  week  with 

B  Acidi   carbolici, 

Spts.  villi  rcct.,  of  each  f5ss  (15.00  c.c). 

Or,  50  per  cent,  trikresol  may  be 
employed. 

Within  recent  years  I  have  em- 
ployed a  chrysarobin  ointment  which 
has  given  me  more  uniformly  good 
results  than  any  other  topical  appli- 
cation : — 

IJ   Chrysaro- 

biiii   gr.  x-xxv   (0.65-1.62  Gm.). 

Lanolini  ...   3j    (4.00  Gm.). 
Adeps    beii- 

zoat 3vij  (27.21  Gm.). 

M.  Rub  in  in  small  quantity.  Protect  the 
eyes   from  contact  with  ointment. 

The  routine  treatment  adopted  by  the 
writer  is  of  an  antiseptic  nature.  The 
head  is  washed  daily  for  several  min- 
utes with  a  strong  tar  soap,  which  is 
then  sluiced  off  and  the  head  dried. 
Then  the  scalp  is  treated  successively 
with  2  per  cent,  sublimate  solution, 
absolute  alcohol,  with  the  addition  of 
J/2  to  1  per  cent,  naphthol,  and  finally 
with  2  per  cent,  salicylic  acid  in  oil. 
In  all  moderately  fresh  cases  the  dis- 
ease is  brought  to  a  standstill  at  once. 
O.  Lassar  (Dermat.  Zeit.,  Sept., 
1900). 

Cases  under  the  author's  observation 
that  were  benefited  or  cured  by  appli- 
cations of  chrysarobin  ointment,  10  to 
15  per  cent,  strength,  used  daily  for  a 
week  or  ten  days,  followed  by  pure 
carbolic  acid  applied  lightly  with  a 
swab.  The  ointment  referred  to  sets 
up  considerable  inflammation,  and  must 
be  used  cautiousl3^  When  this  inflam- 
mation has  subsided,  areas  here  and 
there  the  size  of  a  silver  dollar  are 
touched  from  time  to  time  with  the 
acid.  The  results  in  the  cases  given 
were  highly  satisfactory.  E.  J.  Emerick 
(Columbus  Med.  Jour.,  Feb.,  1901). 


A  preparation  of  30  per  cent,  of 
chrysarobin  applied  for  two  to  eight 
weeks  in  alopecia  areata  causes  vascular 
dilatation,  thickening  of  the  vascular 
walls,  proliferation  of  the  pSrithelial 
cells,  infiltration  of  the  connective  tis- 
sue round  the  vessels,  and  hypertrophy 
of  the  connective-tissue  cells.  Numer- 
ous mast  cells  were  seen  round  the  ves- 
sels. In  some  places  there  were  poly- 
nuclear  leucocytes,  but  no  agglomeration 
of  lymphocytes.  In  the  upper  layers  of 
the  epidermis  there  was  edema,  with 
the  formation  of  parakeratotic  des- 
quamative lamella,  and  in  the  deeper 
layers  there  was  proliferation  of  the 
prickle  cells  round  the  follicular  ori- 
fices, which  gives  rise  to  the  formation 
of  the  cellular  sheaths,  in  the  center  of 
which  new  hairs  form.  By  repetition 
of  the  chrysarobin  irritation  this  cellu- 
lar proliferation  is  repeated  till  new 
follicular  sheaths  are  produced.  New 
sebaceous  glands  are  also  forxned  later- 
ally. Finally,  new  arrector  muscles 
form  and  new  papillae,  in  which  develop 
new  hairs.  Hodara  (Jour,  des  mal. 
cut.  et  syph.,  Sept.,  1903). 

The  following  treatment  has  given 
the  most  satisfactory  results :  Every 
night  for  one  week  the  aflfected  spots 
should  have  w^ell  rubbed  into  them  an 
ointment  of  chrysarobin,  of  a  strength 
of  from  20  grains  to  2  drams  of  the 
drug  to  1  ounce  of  petrolatum.  If  the 
disease  is  not  checked  this  treatment 
should  be  repeated.  After  the  disease 
has  stopped  spreading,  precipitated  sul- 
phur ointment  (1  to  2  drams  to  the 
ounce)  should  be  used.  Severe  or 
chronic  cases  may  call  for  other  meas- 
ures. Dillingham  (Amer.  Med.,  Mar. 
12,  1904). 

Case  of  a  young  girl  in  which  there 
was  a  circular  patch  three  inches  in 
diameter  on  the  scalp  at  the  side  of  the 
occiput,  hairless,  smooth,  and  shining. 
The  treatment  consisted  in  painting  it 
with  a  30  per  cent,  solution  of  formal- 
dehyde. This  was  done  every  day  for 
the  first  week  or  two,  until  signs  of 
inflammatory  reaction  appeared.  The 
treatment  was  then  suspended,  and  a 
sedative  ointment  applied.  When  the 
inflammation    subsided    the     formalde- 


582 


ALUM    (SAJOUS). 


hyde  was  again  continued,  stopping  the 
application  as  soon  as  inflammatory- 
trouble  appeared.  This  routine  of 
treatment  was  persevered  in  for  about 
six  or  nine  months.  About  this  time 
a  growth  of  hair  made  its  appearance, 
continued  to  grow,  and  in  every  way 
corresponded  with  the  surrounding  hair. 
One  year  after  cessation  of  treatment 
the  growth  of  hair  was  continuing  in 
a  perfectly  normal  way.  J.  J.  Mc- 
Inerny  (Brit.  Med.  Jour.,  Jan.  25, 
1908). 

The  faradic  current  applied  with  a 
wire  brush  electrode  is  often  useful,  as 
is  likewise  the  use  of  high-frequency 
currents.  In  obstinate  cases  blister- 
ing of  the  affected  areas  may  be  re- 
sorted to. 

PHOTOTHERAPY.— Many  writ- 
ers, including  Finsen,  Hyde,  Mont- 
gomery, Kromayer,  and  others,  have 
testified  to  the  value  of  actinic  light 
rays  in  this  disease.  It  is  admitted  that 
many  cases  in  which  light  is  used  might 
have  recovered  spontaneously.  Kro- 
mayer's  results,  however,  in  cases  of 
extensive  and  even  total  alopecia  of 
years'  standing  indicate  that  light 
therapy  is  one  of  the  most  useful 
measures  in  the  treatment  of  this  dis- 
ease. 

The  iron  arc  or  carbon  arc  may 
be  employed.  The  ordinary  London 
Hospital  type  of  lamp  suffices  for  this 
purpose  and  permits  of  the  exposure 
of  an  area  the  size  of  a  silver  dollar. 
Reaction  varying  in  degree  from  an 
erythema  to  the  formation  of  a  blister 
results  at  the  end  of  some  hours.  The 
same  area  can  be  again  treated  after  a 
lapse  of  two  or  three  weeks. 

Cases  illustrating  the  rapid  improve- 
ment under  phototherapy  with  the 
ultraviolet  rays.  Success  was  ob- 
tained in  many  cases  in  which  pre- 
vious  measures  applied  for  months 
had  failed  to  benefit.  Joachim  (Deut. 
med.  Woch.,  May  13,  1909). 


Piffard's    iron    spark-gap    lamp — a 

small  lamp  made  of  rubber  with  a 
handle  «» to  hold  it^recommended. 
For  use  it  is  attached  to  a  coil.  The 
quartz  lens  is  removed  in  treatment, 
as  it  allows  only  ultraviolet  rays  to 
pass  through.  The  lamp  is  held  just 
far  enough  away  from  the  scalp  to 
prevent  sparking,  and  continued  for 
five  to  ten  minutes,  and  the  applica- 
tion is  repeated  in  two  to  four  days. 
Heat  is  thrown  out  by  the  lamp  and 
the  skin  gets  reddened.  G.  T.  Jack- 
son (Jour,  of  Cutan.  Dis.,  Jan.,  1910). 

Jay  F.  Schamberg, 

Philadelphia. 

ALSOL.  See  Aluminum:  Alu- 
minum   ACETOTARTRATE. 

ALUM  (Ahimen). — The  alum  used 
in  medicine  is,  chemically,  the  double 
sulphate  of  aluminum  and  potas- 
sium [A1K(S04)2+12H20].  It  oc- 
curs in  large,  octahedral,  translucent 
crystals,  or  as  a  colorless  powder,  odor- 
less, but  with  a  sweetish,  strongly  as- 
tringent taste.  When  left  in  an  open 
bottle,  the  salt  becomes  whitish  on  the 
surface,  owing  to  the  absorption  of 
ammonia  from  the  air.  Dried,  "burnt," 
or  exsiccated  alum  (Ahimen  Exsicca- 
tiim),  i.e.,  alum  from  which  the  water 
of  crystallization  has  been  driven  out 
by  heating,  occurs  as  a  white,  granular, 
strongly  hygroscopic  powder. 

DOSE. — The  dose  of  alum  for  in- 
ternal use  (rarely  employed)  is  5  to  30 
grains  (0.03  to  2.0  Gm.)  ;  the  average 
dose  is  7^  grains  (0.5  Gm.).  To  se- 
cure an  emetic  effect,  1  to  2  drams  (4 
to  8  Gm.)  must  be  given. 

MODES  OF  ADMINISTRA- 
TION.— Alum  is  soluble  in  9  parts  of 
cold  water  (the  saturated  solution  thus 
containing,  roughly,  10  per  cent.),  and 
in  0.3  parts  of  boiling  water.  It  is 
completely  insoluble  in  alcohol,  but  dis- 
solves readily  in  warm  glycerin.    Dried 


ALUM    (SAJOUS). 


583 


alum,  possessing  greater  concentration 
than  the  crystalHne  form,  requires  more 
water  for  dissolution — 17  parts  of  cold 
and  1.4  parts  of  boiling  water.  When 
exhibited  for  other  purposes  than  as 
an  emetic,  alum  is  best  given  in  a  fla- 
vored syrup,  e.g.,  syrup  of  orange  peel. 
When  it  is  used  to  secure  emesis,  a 
small  amount  of  simple  syrup  may  be 
employed  as  vehicle.  The  subsequent 
ingestion  of  warm  water  augments  its 
emetic  effect.  For  astringent  gargles, 
sprays,  anhydrotic  lotions,  and  rectal 
or  vaginal  injections,  solutions  contain- 
ing 21/4  to  20  grains  (0.15  to  1.2  Gm.) 
of  alum  to  the  ounce  (30  c.c.)  of  water 
should  be  prescribed.  When  an  astrin- 
gent eye-wash  is  desired,  2  or  3  grains 
(0.12  to  0.20  Gm.)  of  alum  to  the 
ounce  of  water  may  be  used.  The  "alum 
curd,"  made  by  adding  to  a  pint  (473 
c.c.)  of  milk  2  drams  (8  Gm„)  of  alum, 
boiling  the  mixture,  and  straining  off 
the  curd,  is  also  a  useful  preparation 
for  this  purpose.  Dried  alum,  being 
anhydrous,  is  especially  adapted  for 
use  as  a  dusting  powder,  for  insuffla- 
tion, and  in  ointments.  It  is  applied  to 
superficial  growths  as  an  escharotic.  A 
glycerite  of  alum  is  official  in  the  Brit- 
ish Pharmacopoeia. 

INCOMPATIBLES.— The  salts  of 
aluminum,  including  alum,  are  incom- 
patible with  the  alkalies  and  carbonates 
of  the  alkali  metals;  with  the  tartrates; 
with  tannic  acid,  and  with  salts  of  iron, 
mercury,  and  lead. 

CONTRAINDICATIONS.— In 
individuals  subject  to  bronchial  irrita- 
tion, the  long-continued  use  of  alum  is 
inadvisable,  in  view  of  the  exciting  ef- 
fect it  exerts  on  these  structures. 

PHYSIOLOGICAL  ACTION.— 
When  applied  externally  alum  causes 
hardening  of  the  skin,  or,  if  used  in 
concentrated   solution,    exerts    a    slight 


caustic  effect.  Whenever  it  is  brought 
in  contact  with  albumin,  as  occurs  when 
it  is  applied  to  a  denuded  area,  the  al- 
bumin is  coagulated.  The  precipitate  is 
soluble,  however,  if  an  excess  of  albu- 
min be  present.  The  astringent  and 
antiseptic  effects  of  alum  and  other 
aluminum  salts  depend  upon  this  coag- 
ulating property.  Their  power  of  pen- 
etrating into  tissue-cells  is,  however, 
very  limited  (Siem). 

Small  doses  of  alum  taken  orally  at 
first  stimulate  the  flow  of  saliva,  then 
reduce  it  through  their  astringent  ef- 
fect. The  buccal  mucosa  becomes 
whitish  and  shriveled,  owing  to  coagu- 
lation of  the  albuminous  constituents, 
and  the  enamel  of  the  teeth  is  likely  to 
crack  in  places.  On  reaching  the  stom- 
ach, the  drug  causes  a  decrease  in  the 
amount  of  gastric  juice  secreted,  and 
coagulates, the  pepsin.  A  similar  effect 
beiijg  exerted  in  the  intestinal  canal, 
constipation  results.  In  larger  doses, 
the  emetic  effect  of  alum  becomes  man- 
ifest, and  a  purgative  effect  may  also  he 
noted. 

UNTOWARD  EFFECTS  AND 
POISONING.— The  injurious  effect 
of  alum  on  the  teeth  may  be  avoided 
(1)  if  care  be  taken  to  cleanse  them 
well  at  once  after  employing  an  alum 
gargle  or  mouth-wash;  (2)  by  limiting 
the  use  of  alum  to  applications  of  a 
strong  solution  or  of  the  solid  salt  in 
all  cases  in  which  local  astringent  ef- 
fects will  suffice.  The  unfavorable  ac- 
tion of  alum  when  long  employed  by 
persons  subject  to  bronchial  irritation 
has  already  been  referred  to. 

Large  amounts  of  alum  taken  inter- 
nally cause  nausea,  vomiting,  pain  in 
the  abdomen,  and  diarrhea,  owing  to 
the  inflammation  of  the  gastrointestinal  ' 
mucosae  produced  through  the  cellular 
albumins. 


584 


ALUM    (SAJOUS). 


Case  in  which,  through  gargling  with 
a  concentrated  alum  solution,  a  portion 
of  the  fluid  was  accidentally  swallowed. 
This  was  followed  by  severe  abdominal 
pains,  vomiting  of  mucus  and  blood 
(39  times),  and  voiding  of  blood- 
stained urine.  Recovery  only  after  the 
lapse  of  thirteen  days.  Kramolin 
(Therap.  Monatsh.,  325,  1902). 

Alum  baking  powders  and  pastry  to 
which  alum  has  been  added  in  order  to 
whiten  the  product  are  possible  sources 
of  gastrointestinal  irritation, though  the 
amount  of  aluminum  liberated,  at  least 
in  the  case  of  bread  baked  with  alum 
powders,  is  often  so  slight  as  to  be  of 
doubtful  irruportance. 

THERAPEUTIC  USES.  — As  an 
Astringent. — This  is  the  chief  use  of 
alum.  Combined  with  it  is  an  antisep- 
tic effect,  which  is  also  of  value. 

In  all  catarrhal  and  relaxed  states 
of  the  mucous  membranes,  as  well  as 
in  certain  skin  affections,  alum  is  bene- 
ficial when  locally  applied.  Aqueous 
solutions  of  from  5  to  20  grains  to  the 
ounce  (1  to  4  per  cent.)  strength  are 
chiefly  employed;  stronger  solutions  in- 
duce undesirable  secondary  irritation. 

In  catarrhal  throat  afTections  fluid 
preparations  containing  alum  (1  to  5 
per  cent.)  form  a  useful  gargle  or 
spray.  Since  alum  is  injurious  to  the 
teeth,  the  mouth  should  be  washed 
out,  preferably  with  some  alkaline  so- 
lution, after  using  this  drug.  A 
glycerite  of  alum  (10  to  20  per  cent, 
solution  of  alum  in  glycerin,  the  prep- 
aration of  which  is  greatly  facilitated 
by  heating)  is  very  efficacious  when 
applied  locally  in  subacute  pharyn- 
gitis and  laryngitis,  especially  where 
a  tendency  to  edema  of  the  tissues  in- 
volved is.  present.  For  the  relief  of 
hoarseness  or  of  tickling  sensations 
in  the  throat,  a  mixture  of  equal  parts 
of  powdered  alum  and  sugar,  placed 


on    the    tongue    and    allowed    slowly 

to   dissolve,   is   productive   of  benefit 

(Bunnell). 

In    acute    coryza    alum    has    been 

incorporated    in    snuff,    to    which    it 

imparts     astringency.      The     following 

preparation  is   suitable   for  use  in  the 

early  stages  of  coryza: — 

IJ  Alum    3  grs.  (0.2  Gm.) . 

Morphine  sulphate    .  2  grs.  (0.13  Gm.). 
Cocaine  hydrochlo- 
ride     Igr.   (0.065  Gm.). 

Camphor, 
Bismuth   of  each   2  drs.  (7.77  Gm.). 

M.  bene.  Sig. :  To  be  used  as  snuff  every 
two  hours ;  a  small  quantity  in  each  nostril. 

In  follicular  tonsillitis  and  diph- 
theria alum  in  pencil  form  may  be 
applied  to  the  involved  surfaces  with 
benefit. 

In  conjunctivitis  alum  may  also  be 
used.  A  0.5  per  cent,  solution  may  be 
used  as  a  lotion,  or  the  alum  curd, 
made  by  the  addition  of  powdered 
alum  to  milk  or  white  of  egg  until 
a  curdy  mass  is  formed,  may  be  ap- 
plied to  the  eye  every  two  hours. 
Similar  applications  prove  effective 
in  ecchymosis  of  the  eyelid  (black 
eye).  In  gonorrheal  ophthalmia  alum 
has  also  been  used  in  a  solution  con- 
taining 6  grains  of  the  salt  in  1  ounce 
of  water,  applied  four  times  daily.  In 
granular  conjunctivitis  a  crystal  of 
alum  may  be  drawn  over  the  involved 
mucous  surface  after  turning  the  lid 
(Bunnell). 

In  salivation  or  ptyalism  of  mer- 
curial origin  a  4  per  cent,  solution  of 
alum  may  be  employed  for  its  astrin- 
gent action. 

In  the  treatment  of  night-sweats,  or 
in  sweating  of  the  hands  and  feet 
(hyperidrosis) ,  washing  the  skin  sur- 
faces with  a  0.5  per  cent,  solution  of 
alum  will  markedly  improve  the  con- 
dition. 


ALUM    (SAJOUS). 


585 


In  chilblains  a  4  per  cent,  solution 
of  alum  has  been  applied  with  benefit. 

In  gonorrhea  and  leucorrhea  alum 
has  been  used  as  an  astringent  injec- 
tion or  douche  in  I2  to  2  per  cent, 
strength. 

In  pruritus  vulvas  a  4  per  cent,  so- 
lution of  the  salt  will  not  infrequently 
relieve   the   itching. 

In  ingrowing  toenail  with  granula- 
tions absorbent  cotton  soaked  in  a  6 
per  cent,  solution  of  alum  may  be  in- 
troduced under  the  edge  of  the  nail. 

In  chronic  dysentery  a  1  per  cent, 
solution  of  alum  is  sometimes  em- 
ployed as  a  rectal  injection. 

As  a  styptic  alum  is  likewise  an 
effective  agent. 

In  epistaxis  it  will  often  act 
promptly.  Pledgets  of  cotton  should 
be  dipped  in  a  saturated  solution  of 
alum  and  packed  in  the  bleeding  cav- 
ity; they  may  be  left  in  until  all 
danger  of  recurrence  has  passed — 
generally  about  twelve  hours.  In 
minor  degrees  of  hemorrhage  the 
alum  solution  may  be  sprayed  in,  or 
powdered  alum  may  be  used  as  snuff 
or  introduced  by  means  of  an  insuf- 
flator. 

Similarly,  in  hemorrhage  succeed- 
ing upon  the  extraction  of  teeth,  the 
placing  in  the  cavity  of  cotton  dipped 
in  a  saturated  solution,  or  the  intro- 
duction of  powdered  alum,  will  often 
be  effective  in  arresting  the  bleeding. 

In  hemoptysis  a  fine  spray  of  5  per 
cent,  alum  solution  is  claimed  to 
have  been  productive  of  benefit. 

In  the  intestinal  hemorrhage  of  ty- 
phoid fever  alum  has  been  recom- 
mended by  many  clinicians,  Whitla 
in  particular.  It  is  believed  to  do 
good  in  this  condition  through  its 
antiseptic  properties,  as  well  as 
through  its  astringency. 


In  uterine  hemorrhage  of  all  kinds 
alum  is  a  useful  styptic.  It  may  be 
employed  as  an  injection  in  the 
strength  of  1  dram  to  the  pint,  or, 
as  R.  Beverly  Cole  recommended,  an 
egg-shaped  piece  of  alum  may  be 
inserted  into  the  uterine  cavity.  Not 
only  is  the  styptic  effect  produced, 
but  the  tissues  of  the  uterus  are  stim- 
ulated and  the  organ  is  caused  firmly 
to  contract. 

As  a  Caustic. — Dried  ("burnt") 
alum,  which  exerts  an  escharotic  ef- 
fect, owing  to  the  fact  that  in  addi- 
tion to  the  inherent  properties  of 
alum  it  withdraws  water  from  the 
tissues,  may  be  applied  to  exuberant 
granulations,  condylomata,  chronic 
conjunctival  inflammations,  etc. 

Burnt  alum  may  also  be  used  as  a 
dressing  for  sluggish  ulcerations  and 
as  an  application  to  swollen  gums 
and  in  ulcerative  stomatitis  (Bun- 
nell). 

As  an  Emetic. — In  doses  of  1  or  2 
drams  alum  has  been  used  as  an 
emetic,  especially  in  the  treatment  of 
croup  in  children.  A  teaspoonful  of 
the  salt  may  be  dissolved  in  6  table- 
spoonfuls  of  a  mixture  of  syrup  and 
water,  equal  parts,  and  administered 
every  fifteen  minutes. 

This  sometimes  serves  quickly  to  ar- 
rest an  impending  attack  of  croup,  the 
astringent  effect  of  the  salt  upon  the 
mucosa  of  the  throat  contributing  in  the 
benefit  by  counteracting  the  local  hyper- 
emia. 

As  a  Stimulant  to  Peristalsis. — In 
doses  of  %  dram  every  four  hours 
alum  has  been  found  to  induce  purga- 
tion. The  large  amount  of  watery  fluid 
thrown  out  from  the  mucosae  in  the 
presence  of  alum  apparently  obviates 
its  irritating  influence  on  these  mem- 
branes.    In   tympanites    due  to  peri- 


586 


ALUMINUM    (SAjOUS). 


toneal  inflammation  succeeding  upon 
abdominal  operations  in  cases  suffer- 
ing from  infective  states  of  the  ab- 
dominal viscera,  the  high  rectal  in- 
jection of  an  ounce  of  alum  in  a  quart 
of  water  has  been  found  effectively 
to  excite  contractions  of  the  paretic 
gut. 

Case  in  which  Epsom  salt,  calomel, 
soap  and  water,  castor  oil,  glycerin, 
turpentine,  and  oxgall  were  success- 
ively used  without  avail.  A  solution 
of  an  ounce  of  powdered  alum  in  a 
quart  of  warm  water  was  injected  into 
the  rectum,  and  in  ter  minutes  flatus 
escaped  from  the  rectum.  In  an  hour 
the  enema  was  repeated  successfully. 
The  patient  was  practically  convales- 
cent on  the  following  day.  Since  this 
case,  the  author  has  used  the  alum 
enema  in  hundreds  of  cases,  and  always 
with  good  results.  Sometimes  it  is 
necessary  to  repeat  the  injection  be- 
fore it  will  act,  and  this  can  be  done 
with  safety  an  indefinite  number  of 
times. 

There  is  sometimes  some  pain,  not 
severe,  attending  its  use.  Injected 
like  any  other  enema,  probably  in  no 
instance  does  it  go  above  the  sigmoid 
flexure.  The  throwing  off  by  the  bowel 
of  a  tubular  cast  is  of  no  importance, 
as  it  is  composed  simply  of  mucus 
whose  albuminous  elements  have  been 
coagulated  by  the  alum. 

The  alum  seems  to  have  as  specific 
an  action  in  inducing  intestinal  peri- 
stalsis as  has  castor  oil  when  taken  into 
the  stomach.  It  does  not  produce  a 
serous  exudation  from  the  intestinal 
walls,  and  for  that  reason  the  author 
prefers  it  to  Epsom  salt  when  the 
stomach  will  retain  it.  During  nine 
years  in  which  alum  enema  was  used, 
percentage  of  mortdity  in  abdominal 
work  has  been  a  little  less  than  one- 
half  of  what  it  was  during  the  pre- 
ceding seven  years.  Hardon  (Amer. 
Jour,  of  Obstet.,  June,  1901). 

C.  E.  DE  M.  Sajous 

AND 

L.  T.  DE  M.  Sajous, 

Philadelphia. 


ALUMINUM  (Aluminium).  —  A 
bluish-white,  silvery  metal,  noted  for 
its  low  specific  gravity  (2.7)  and  its 
unalterability  on  exposure  to  the  air. 

The  most  important  of  the  com- 
pounds of  the  metal  aluminum  em- 
ployed in  medicine,  viz.,  the  double 
sulphate  of  aluminum  and  potassium, 
has  already  received  separate  consid- 
eration (v.  Alum).  Numerous  other 
salts  have  been  used,  chiefly  exter- 
nally, as  astringents  and  antiseptics. 

Taken  internally,  the  salts  of.  alumi- 
num are,  according  to  some  observers, 
not  all  absorbed  from  the  gastrointesti- 
nal tract,  this  accounting  for  the  fact 
that  no  functional  disturbances  in  the 
organism  at  large  occur  as  a  result  of 
their  ingestion.  According  to  others, 
however,  alum  (and  probably  other 
salts)  is  absorbed,  in  extremely  small 
amount,  in  the  alimentary  canal,  and 
is  eliminated  with  the  bile  and  urine. 
When  administered  experimentally 
to  animals  by  subcutaneous  injection, 
soluble  salts  of  aluminum  cause  no 
symptoms  at  all  until  several  days  or 
even  weeks  later  (Siem),  when  the 
metal  is  no  longer  present  in  the  cir- 
culation. In  mammals  the  symptoms 
appear  in  from  three  to  five  days,  and 
are  in  many  ways  similar  to  those  of 
subacute  arsenic  poisoning.  The  ani- 
mal shows  loss  of  appetite,  obstinate 
constipation,  emaciation,  and  languor. 
Next  there  appears  vomiting.  Vol- 
untary movements,  executed  only 
upon  coercion,  are  attended  with 
trembling  and  twitching.  Sometimes 
there  is  general  tremor  or  convulsive 
twitching,  and  sometimes  extreme 
weakness  or  partial  paralysis  of  the 
posterior  limbs.  There  is  complete 
loss  of  sensibility  to  pain,  though 
iconsciousness  is  retained.  Finally, 
control  of  the  tongue  and  the  power 


Aluminum  (sajous). 


587 


tyf  swallowing  are  completely  lost,  sa- 
liva dribbling'  from  the  mouth.  The 
symptoms  correspond  precisely  to 
.those  of  human  acute  bull^ar  paraly- 
sis. Such  phenomena  never  result 
from  the  oral  use  of  aluminum  salts, 
even  where  long-  continued  (Soll- 
mann).  Diarrhea  and  albuminuria 
appear  before  death.  On  post-mortem 
examination  the  gastrointestinal  mu- 
cosae are  found  hyperemic  and  swol- 
len, and  the  kidneys  and  liver  fre- 
quently show  fatt}^  degeneration,  the 
former  presenting,  in  addition,  corti- 
cal hemorrhages. 

Following  are  some  of  the  more 
important  salts  of  aluminum  em- 
ployed in  medicine : — 

Aluminum  Hydroxide  {Alumini 
Hydroxidum),  Al(OH)3,  made  by 
precipitating  a  soluble  salt  of  alumi- 
num with  an  alkali  or  alkaline  car- 
bonate. It  occurs  as  a  light,  amor- 
phous, colorless,  tasteless  powder, 
soluble  in  acids  and  alkalies.  It  is 
used  as  an  astringent  in  inflamma- 
tory skin  affections. 

Aluminum  Sulphate  {Alumini  Sul- 
phas), Al2(S04)3  4-18H20,  prepared 
from  the  hydroxide  by  dissolving  it 
in  dilute  sulphuric  acid.  It  occurs  as 
a  white,  crystalline  powder  or  in  larger 
crytals  or  pencils,  and,  like  alum,  has 
a  sweetish  and  astringent  taste.  It 
is  freely  soluble  in  water,  and  has 
been  used  for  much  the  same  pur- 
•  poses  as  alum  itself,  viz.,  as  an  astrin- 
gent, antiseptic,  and  caustic  in  the 
treatment  of  affections  of  the  nose 
and  throat,  including  enlarged  tonsils 
and  nasal  polypi ;  of  the  uterus,  includ- 
ing endometritis ;  as  a  lotion  for  foul 
ulcers,  and  in  vaginal  conditions  as- 
sociated with  offensive  discharges. 
The  strength  of  the  solutions  used  is 
the  same  as  with  alum. 


The  following  aluminum  compounds 
are  non-official : — 

Aluminum  Acetate  (basic),  AloO,- 
4C2H;{02  +  4Ii20.  Obtained  in  solid 
form  from  its  solutions  by  rapid  dry- 
ing on  glass  at  a  low  temperature, 
this  salt  occurs  as  a  colorless,  crystal- 
line or  amorphous  powder  which  is 
insoluble  in  water.  It  is  antiseptic 
and  astringent,  and  has  been  used  in- 
ternally in  dysentery  in  doses  of  5  to 
10  grains  (0.3  to  0.6  Gm.).  An  8  per 
cent,  solution  of  aluminum  acetate  is 
known  as  "liquor  Burowii,"  which 
has  been  extensively  used  as  an  appli- 
cation in  skin  affections,  and  in  sup- 
purating wounds.  One  to  3  per  cent, 
solutions  are  useful  as  a  mouth-wash, 
and  are  particularly  effective  in  over- 
coming fetid  breath.  In  a  solution  of 
1  to  150  strength,  this  salt  of  aluminum 
may  be  used  as  an  astringent  enema  in 
affections  calling  for  such  a  measure. 

Antiseptic  properties  of  moist  appli- 
cations of  a  solution  of  aluminum 
acetate  used  quite  generally  by  the 
author  after  operations  where  there  is 
the  slightest  danger  of  infection.  The 
solution  is  also  invaluable  in  the  mouth, 
particularly  for  necrosis  and  suppura- 
tion, where  it  does  more  good  than 
mouth-washes.  An  excellent  method  of 
treating  tears  of  the  perineum,  after 
confinement,  is  to  apply  gauze  saturated 
with  the  solution,  and  to  have  the  pa- 
tient lie  on  the  abdomen  for  a  few 
days.  F.  Weitlaner  (Klin,  therap. 
Woch.,  Nu.  6,  1908). 

Usefulness  of  aluminum  acetate  solu- 
tion emphasized.  For  certain  surgical 
purposes  this  is  one  of  the  best  anti- 
septic solutions,  though  it  is  unknown 
to  most  surgeons  and  practitioners. 
Burns  may  be  treated  with  dressings 
wetted  with  a  1  per  cent,  solution  of 
aluminum  acetate.  This  solution,  while 
.  antiseptic,  is  also  non-toxic,  non-irri- 
tant, and  yet  markedly  astringent.  It 
is  not  to  be  employed  in  surgical  opera- 
tions, as  it  spoils  steel  instruments ;  but 


588 


ALUMINUM    (SAJOUS). 


as  an  antiseptic  for  moist  fomentation 
of  wounds  that  are  infected  or  prob- 
ably unclean,  or  as  a  medicament  for 
a  bath  in  which  to  place  an  infected 
.  hand  or  foot  for  continuous  irrigation, 
.  it  is  to  be  strongly  recommended.  The 
common  strength  is  that  of  1  dram  of 
the  liquor  aluminii  acetatis  of  the  Ger- 
man Pharmacopoeia  (a  7^  per  cent, 
solution)  to  1  fluidounce  of  water. 
There  is  no  danger  of  poisoning  from 
it.  By  the  employment  of  continuous 
irrigation  by  means  of  a  bath  of  the 
1  per  cent,  solution,  pyogenically  in- 
fected hands  and  feet,  which  but  for 
the  action  of  the  solution  would  have 
called  for  amputation,  have  been  saved. 
For  dermatitis,  whatever  its  cause;  for 
suppurating  open  wounds,  and  for  cu- 
taneous erysipelas,  much  is  to  be  said 
for  the  favorable  results  obtained.  One 
objection  that  should  be  mentioned  is 
that  after  three  weeks  of  continuous 
irrigation  of  a  member  such  as  the 
hand  the  surface  tissues  may  assume  a 
ligneous  hardness.  M.  F.  Waterhouse 
(Hospital,  Aug.  27,  1910). 

Aluminum  Acetotartrate  (Alsol), 
prepared  by  mixing  a  5  per  cent,  solu- 
tion of  basic  aluminum  acetate  with 
a  2  per  cent,  solution  of  tartaric  acid 
and  evaporating"  to  drjmess.  It  occurs 
in  colorless  crystals,  or  in  whitish 
amorphous  masses  having  a  slightly 
acid,  astringent  taste.  It  dissolves 
slowly,  but  completely,  in  water,  but 
is  insoluble  in  alcohol  and  ether. 

This  substance  has  an  action  sim- 
ilar to  that  of  aluminum  acetate,  and 
is  one  of  the  best  of  the  aluminum 
salts  used  in  medicine.  It  has  been 
employed  largely,  though  not  exclu- 
sively, in  diseases  of  the  respiratory 
passages.  Thus  in  G.05  to  2  per  cent, 
solutions  it  has  been  used  as  a  nasal 
douche.  Mixed  with  2  parts  of  pow- 
dered boric  acid  it  may  be  used  as  a 
snufif.  In  tonsillitis  a  1  per  cent,  so- 
lution of  it  makes  a  suitable  gargle. 
Strong  solutions    {e.g.,   50  per   cent.) 


have  been  employed  with  advantage 
in  the  treatment  of  chilblains  and 
skin  diseases  of  various  kinds — also 
in  wounds  as  disinfectants.  Eye  af- 
fections, such  as  ophthalmia  neona- 
torum, chronic  types  of  conjunctivi- 
tis, etc.,  have  also  been  treated  with 
this  salt. 

In  a  5  per  cent,  solution,  alsol  inhibits 
the  growth  of  gonococci,  streptococci, 
and  anthrax  bacilli.  In  the  treatment 
of  wounds,  it  is  astringent,  disinfect- 
ant, and  antiseptic  and  does  not  irri- 
tate the  tissues.  In  a  1  per  cent,  solu- 
tion, it  is  useful  as  a  gargle  in  ton- 
sillitis, J.  W.  Frieser  (Wiener  klin. 
Rundschau,  Aug.  12,  1900). 

Alsol  in  a  5  per  cent,  solution  de- 
stroyed the  spores  of  anthrax  in  ten 
hours,  acetate  of  aluminum  in  an  8 
per  cent,  solution  in  two  hours,  while 
carbolic  acid  in  a  5  per  cent,  solu- 
tion had  no  effect  whatever  on  their 
development.  In  the  case  of  Strepto- 
coccus pyogenes,  Staphylococcus  pyog- 
enes aureus,  the  gonococcus,  and  the 
tubercle  bacillus,  however,  carbolic  acid 
has  a  greater  bactericidal  power  than 
acetate  of  aluminum.  The  combina- 
tion of  the  acetate  with  the  tartrate 
greatly  raises  the  bactericidal  power,  so 
that  alsol  is  considerably  more  potent 
than  carbolic  acid.  Aufrecht  (Deut. 
aertzl.  Zeitung,  Feb.,  1900). 

Alsol  exerts  an  action  similar  to  the 
acetate  of  aluminum.  It  is  said  to 
possess  a  somewhat  stronger  disinfect- 
ant action  than  the  same  strength  solu- 
tion of  carbolic  acid,  and  is  mildly 
astringent  at  the  same  time.  The 
author  employed  it  in  a  concentration 
of  from  %.  to  y2  per  cent.  Finding  that 
warm  and  cold  compresses  are  of  value 
in  the  treatment  of  certain  eye  affec- 
tions, he  attempted  to  extend  their  use 
by  employing  alsol.  In  blennorrhoea 
neonatorum  he  washed  the  eyes  out 
every  half  an  hour,  both  during  the 
day  and  night,  and  obtained  excellent 
results.  The  direct  forms  of  treat- 
ment, e.g.,  painting  with  silver  nitrate, 
etc.,  must  be  carried  out  as  well,  the 
alsol  solution  only  acting  as  a  disin- 


ALUMINUM    (SAJOUS). 


589 


fectant  and  mild  astringent.  In  acute 
conjunctivitis  and  acute  granuloma 
cold  compresses  applied  for  ten  to 
twenty  minutes  three  or  four  times 
a  day  found  of  value.  The  same  re- 
sults were  obtained  in  chronic  con- 
junctivitis and  chronic  trachoma.  In 
scrofulous  ophthalmia  warm  com- 
presses were  applied  three  times  a 
day  for  about  half  an  hour.  In  hor- 
deola and  in  ulcers  of  the  cornea, 
iritis,  etc.,  satisfactory  results  were 
obtained  with  alsol.  L.  Pick  (Therap. 
Monats.,  July,  1903). 

Aluminum  Boroformate,  prepared 
by  saturating  with  freshly  precipi- 
tated and  well- washed  aluminum  a 
solution  of  2  parts  of  formic  acid  and 
1  part  of  boric  acid  in  6  or  7  parts  of 
water.  It  occurs  in  pearly  scales, 
which  are  hygroscopic  and  dissolve 
completely,  though  slowly,  in  water. 
Its.  solution  has  a  sweet,  faintly 
astringent  taste,  and  does  not  co- 
agulate solutions  of  albumin.  Mar- 
tenson  in  1894  recommended  this  salt 
strongly  for  use  as  a  gargle  in  the 
throat  affections  in  children,  prefer- 
ring it  to  all  other  preparations  of 
aluminum. 

Aluminum  Borotannate  (Cutal),  a 
product  of  the  reaction  of  tannic  acid 
with  borax  and  aluminum  sulphate. 
It  is  a  brownish  insoluble  powder, 
which  combines  with  tartaric  acid  to 
form  Aluminum  Borotannotartrate 
(soluble  Cutal). 

This  salt,  in  common  with  the 
other  aluminum  compounds,  is  anti- 
septic and  astringent.  It  has  been 
used  chiefly  in  skin  affections  and  is 
recommended  particularl}^  in  weep- 
ing eczema  and  pruriginous  affec- 
tions. The  following  formula  may  be 
employed : — 

IJ  Aluminum    boro- 
tannate         1  dr.   (4  Gm.) . 

Olive    oil    2^   drs.    (10  Gm.). 

Lanolin.,  to  make  10    drs.    (40   Gm.). 


When  the  flow  of  secretions  has 
been  arrested,  the  drug  may  be  used 
with  advantage  as  a  dusting  powder 
in  the  following  mixture  : — 

I^  Aluminum    boro- 
tannate. 

Zinc  oxide, 

Powdered  talc,  of 

each 2^  drs.  (10  Gm.). 

In  hemorrhoids  Koppel  has  recom- 
mended the  use  of  an  ointment  con- 
taining 10  per  cent,  of  cutal,  and  in 
fissures  of  the  hands  of  one  formu- 
lated thus : — 

IJ  Cutal    ^  dr.    (3  Gm.) . 

Oil  of  sweet  alm- 
onds. 

Lanolin  ..of  each  3^  drs.    (15   Gm.). 

Orange-flower 
water   2>^  fl.  drs.   (10  Gm.). 

Aluminum  borotannotartrate,  or 
soluble  cutal,  has  been  used  in  the 
treatment  of  second-degree  burns,  as 
a  10  per  cent,  solution  in  glycerin  in 
follicular  throat  affections,  in  catar- 
rhal metritis,  in  hemorrhoids,  and  in 
gonorrhea. 

Aluminum  Borotartrate  (Boral),  a 
combination  of  aluminum,  boric  acid, 
and  tartaric  acid.  It  occurs  as  white 
crystals  having  a  sweetish,  astringent 
taste,  and  is  freely  soluble  in  water. 
It  is  useful  in  inflammatory  diseases 
of  the  nose  and  nasopharynx,  in  ery- 
sipelas, and,  in  solution  with  tartaric 
acid,  has  given  good  results  in  gonor- 
rhea. It  may  be  employed  either 
alone  in  watery  solution  or  in  glycer- 
inated  mixtures. 

Aluminum  Carbonate,  AI2  (003)2, 
occurring  in  chalky-white,  easily  pow- 
dered, tasteless  masses.  According 
to  Gawalewski,  it  constitutes  an  ex- 
tremely mild  styptic  and  astringent, 
and  is  hence  better  adapted  than  are 
burnt  alum  and  other  aluminum  prep- 
arations  in   the   treatment  of   ocular 


590 


ALUMNOL. 


affections,  croup,  diarrhea,  hemopty- 
sis, skin  eruptions,  and  hyperidrosis. 

Aluminum  Chloride,  AI2CI6  -|-  12- 
H2O,  a  yellowish  granular,  crystal- 
line, hygroscopic  powder,  soluble  in 
water,  alcohol,  and  ether.  It  has  been 
used  internally  in  tabes  in  doses  of 
11/4  to  4  grains  (0.1  to  0.25  Gm.),  and 
externally  as   a  disinfectant. 

Aluminum  Phenolsulphonate  (Sul- 
phocarbolate),  Al2(C6H4HS04)6,  a 
reddish  powder  with  weak  phenol4ike 
odor  and  a  strongly  astringent  taste, 
soluble  in  water,  alcohol,  and  glycerin. 
It  has  been  recommended  as  a  sub- 
stitute for  iodoform  in  the  treatment 
of  superficial,  circumscribed,  suppu- 
rating lesions,  and  of  cystitis. 

Aluminum  Salicylate,  A1(C6H4- 
OHCOO)3,  a  reddish  powder,  insol- 
uble in  water  and  alcohol,  soluble  in 
alkalies.  Used  as  an  antiseptic  pow- 
der for  insufflation  in  catarrhal  states 
of  the  nasal  and  pharyngeal  mucous 
membranes,  and  in  ozena. 

Aluminum.  Silicate,  Al2Si309,  a 
white  substance,  insoluble  in  water 
and  acids.  It  has  been  recently  rec- 
ommended in  the  treatment  of  gastric 
hyperacidity  and  hyperesthesia. 

Investigations  of  the  action  of  silicate 
of  aluminum  upon  the  gastric  secre- 
tions and  upon  disease  symptoms  re- 
sulting from  abnormalities  of  secretion. 
Under  the  name  'neutralon,  this  sub- 
stance occurs  as  a  fine,  tasteless,  odor- 
less, and  insoluble  powder.  Taken  into 
the  stomach  it  reacts  with  the  excess  of 
hydrochloric  acid  to  form  silicic  acid 
and  aluminum  chloride.  The  latter 
acts  as  a  protective  and  astringent  to 
the  gastric  mucosa  in  a  manner  similar 
to  silver  nitrate  and  bismuth,  and  has 
no  toxic  effect.  In  all  cases  of  hyper- 
acidity or  hypersecretion,  whether  of 
neurotic  origin  or  due  to  organic  disease 
or  injury,  the  remedy  was  found  to  be 
very  effective  in  reducing  the  acidity, 
relieving    pain,    and    aiding    digestion. 


Results  especially  good  in  persistent 
cases  of  hypersecretion  with  motor  in- 
sufficiency. Gastric  hyperesthesia  as- 
sociated with  anemia  and  chlorosis 
favorably  influenced  in  several  in- 
stances. Excessive  acidity  in  cases  of 
gastric  ulcer  was  also  reduced.  The 
drug  was  given  in  doses  of  ^  to  1 
teaspoonful  in  3  ounces  of  water,  one- 
half  to  one  hour  before  meals.  No 
untoward  symptoms.  Rosenheim  and 
Ehrmann  (Deut.  med.  Woch.,  Jan. 
20,  1910). 

C.  E.  DE  M.  Sajous 

AND 

L.  T.  DE  M.  Sajous, 

Philadelphia. 

ALUMNOL  the  aluminum  salt  of 
betanaphthol-disulphonic  acid  [Al2(Cio- 
115011(503)2)3],  is  made  by  adding  a  solu- 
tion of  barium  naphthol-disulphonate  to 
one  of  aluminum  sulphate,  filtering  off  the 
precipitate  of  barium  sulphate,  and  evap- 
orating to  dryness.  It  contains  about  5 
per  cent,  of  aluminum,  and  occurs  as  a 
fine  white  or  slightly  reddish,  non-hygro- 
scopic powder  with  a  sweetish,  astringent 
taste.  It  is  readily  soluble  in  cold  water 
and  in  glycerin,  slightly  so  in  alcohol,  and 
is  insoluble  in  ether.  On  exposure  to  the 
air  it  becomes  darker  in  color,  by  virtue 
of  its  reducing  properties. 

MODE  OF  EMPLOYMENT.— Alum- 
nol  is  employed  chiefly  in  solution,  though 
also  frequently  as  a  dusting  powder.  As 
a  mild  astringent  and  antiseptic  it  is  used 
in  solutions  of  0.5  to  5  per  cent,  strength. 
For  caustic  effects,  a  10  or  20  per  cent, 
solution  may  be  employed.  Where  the 
action  of  several  antiseptics  at  once  is 
desired,  alumnol  may  be  used  in  com- 
bination with  agents  such  as  corrosive  sub- 
limate, resorcin,  etc.;  it  is  incompatible, 
however,  with  silver  nitrate  or  other  re- 
ducible salts,  as  well  as  with  alkalies. 

THERAPEUTIC  USES.— The  almost 
unirritating  and  non-toxic  qualities  of 
alumnol  in  weak  solutions  render  it  avail- 
able as  an  astringent  and  antiseptic  for 
the  treatment  of  chronic  catarrhal  proc- 
esses, and  also  in  sluggish  ulcerations.  In 
acute  cases,  however,  it  generally  proves 
too  irritating  to  be  of  value.  It  has  been 
employed  mainly  in  gynecology  and  gen- 


ALUMNOL. 


591 


itourinary  surgery,  and,  to  a  less  extent,  in 
general  surgery,  laryngology,  and  derma- 
tology. 

In  y2  to  1  per  cent,  solution  alumnol 
was  found  useful  by  Hcinze  and  Liebreich 
in  gonorrheal  endometritis  and  in  colpitis 
not  of  gonorrheal  origin.  Kontz,  employ- 
ing alumnol  in  a  series  of  16  gynecological 
cases,  found  that  cervical  catarrh  and 
simple  perimetritis  yielded  to  its  repeated 
use,  and  that  gonorrheal  vaginitis  was 
readily  cured  by  it.  In  endometritis  ac- 
companied by  adnexal  lesions,  however, 
pain  was  augmented,  owing  to  the  irrita- 
tion. 

This  author  employed  a  3  per  cent,  solu- 
tion for  lavage,  a  10  per  cent,  solution 
in  the  treatment  of  endometritis  and  ero- 
sions, and  powders  and  bougies  of  20  per 
cent,  strength.  Marfan  used  3  per  cent, 
bougies  of  alumnol  in  vulvovaginitis. 

Intra-uterine  injections  of  the  iodide  of 
alumnol  have  been  recommended  by  Gram- 
matikati  as  a  substitute  for  curettement  of 
this  organ. 

Though  alumnol  has  been  claimed  to 
exert  a  peculiarly  destructive  action  on 
gonococci,  its  use  as  an  injection  in 
gonorrhea  in  the  male  has  not  led  to  re- 
sults commensurate  with  early  expecta- 
tions. Casper  employed  it  in  12  cases  of 
acute  gonorrhea,  20  chronic  cases,  4  cases 
of  gonorrheal  epididymitis,  2  of  post- 
gonorrheal  adenitis,  and  2  of  soft  chancre, 
administering  intraurethral  injections  of 
0.25  to  2.0  per  cent,  solutions;  he  did  not 
find  it  superior  to  other  drugs  in  general 
use.  Samter  confirmed  these  findings, 
though  Chotzen  claimed  to  have  obtained 
good  results.  In  the  cases  of  soft  chancre 
in  Casper's  series  healing  was  promoted 
by  the  application  of  alumnol.  Asch  used 
a  10  to  20  per  cent,  solution  for  cauteriz- 
ing the  lacunse  and  crypts  at  the  urethral 
orifice. 

As  a  surgical  antiseptic,  alumnol  is  used 
in  O.S  to  3  per  cent,  solutions.  In  the 
dressing  of  wounds  and  in  ulcerations, 
specific  or  non-specific,  Eraud  found  it  to 
produce  no  irritation  or  pain.  As  a  desic- 
cant  powder  for  wounds  this  author  con- 
siders it  efficacious. 

In  nose  and  throat  practice,  alumnol  has 
been  found  valuable  in  simple  chronic  and 
hypertrophic  rhinitis,  in  ozena,  in  catarrhal 


and  follicular  tonsillitis,  and  in  acute  and 
chronic  pharyngitis.  It  is  used  cither  in  a 
1  per  cent,  solution  as  a  douche,  in  a 
watery  glycerin  solution  (1:5),  to  be  ap- 
plied to  the  affected  parts,  or  as  a  powder, 
mixed  with  starch  (10  to  20  per  cent.),  for 
insufflation.  Stepanicz  found  that  in  acute 
laryngeal  affections  the  roughne-^s  of  voice 
generally  disappeared  after  a  single  in- 
halation of  a  1  per  cent,  solution.  In 
chronic  cases,  insufflations  of  alumnol  and 
starch  (2  to  10  per  cent.)  also  gave  good 
results.  Metzerott  used  alumnol  with 
satisfaction  not  only  in  laryngitis,  pharyn- 
gitis, tonsillitis,  and  peritonsillitis,  but  also 
in  edema,  syphilis,  and  tuberculosis  of  the 
larynx.  In  a  case  of  symptomatic  laryn- 
geal edema,  probably  of  syphilitic  causa- 
tion, with  a  severe  grade  of  stenosis,  the 
administration  of  alumnol  solutions  in  the 
form  of  injections  and  the  steam  spray 
made  it  possible  to  defer  tracheotomy  for 
six  months.  In  the  case  of  a  singer 
troubled  with  subglottic  laryngitis,  with 
wave-like  fluttering  of  the  vocal  cords,  an 
alumnol  spray  gave  early  relief;  also  in 
one  of  chorditis  nodosa  (singer's  nodules), 
strong  solutions  of  the  remedy  proved 
beneficial. 

In  otology  alumnol  has  also  been  em- 
ployed. In  suppurative  otitis  media  Heath 
noticed,  however,  that  it  sometimes  caused 
persistent  burning  sensations,  and  that  it 
tended  to  unite  with  pus  in  the  exter- 
nal meatus  to  form  stone-like  pellets, — a 
peculiarity  condemning  its  use  in  this 
disorder. 

In  dermatology  alumnol  has  been  found 
serviceable  in  powder  form  (12  to  25  per 
cent.),  collodion  (5  to  10  per  cent.),  and 
ointment  (1,  5,  and  12^  per  cent.).  It  has 
proven  effective  in  dermatitis,  acute  eczema 
of  all  sorts,  and  chronic  eczema,  but  in 
syphilis  and  the  parasitic  skin  affections 
did  not  yield  much  benefit.  In  acne  and 
acne  rosacea  as  good  results  have  been 
obtained  with  it  as  by  most  other  methods 
of  treatment.  Chotzen  found  alumnol  effi- 
cacious in  acute  and  chronic  inflammations 
of  the  skin  and  mucous  membranes,  in- 
cluding erysipelas,  favus,  lupus,  soft  chan- 
cre, and  erosions.  Eraud  made  the  state- 
ment that  alumnol  appeared  to  be  useful 
in  certain  varieties  of  pruritus,  especially 
of  the  anus  and  scrotum.  S. 


592 


AMAUROSIS    (HANSELL). 


AMAUROSIS.  -DEFINITION. 

— Amaurosis,  formerly  used  to  desig'- 
nate  partial  or  complete  blindness, 
has  become,  since  the  common  em- 
ployment of  the  ophthalmoscope, 
much  more  limited  in  its  meaning 
and  application.  At  present,  imper- 
fect vision  not  due  to  errors  of 
refraction  or  visible  pathological 
changes  may  be  classified  under 
'■'amblyopia" ;  complete  blindness  of 
one  or  both  eyes  and  usually  that 
form  of  blindness  caused  by  disease 
of  the  nervous  apparatus  of  sight,  the 
retina,  optic  nerve,  and  cerebral  centers 
under  amaurosis. 

[Both  words  should  be  so  used  that  they 
refer  only  to  certain  kinds  of  blindness  which 
are  to  be  described  by  a  preceding  adjective, 
and  unless  thus  defined  their  meaning  is 
vague  and  uncertain,  carrying  no  suggestion 
of  etiology  or  pathology.  When  the  media 
of  the  eye  are  transparent,  normal  or  abnor- 
mal conditions  of  the  fundus  are  as  easily 
diagnosed  by  the  expert  ophthalmologist  as 
are  diseases  of  the  skin  by  the  dermatologist ; 
therefore,  except  as  a  convenience  or  as  a 
substitute  for  the  word  blindness,  amaurosis 
might  well  be  omitted  from  ocular  vocabu- 
lary. Eyes  blinded  by  disease  of  or  trau- 
matism to  the  middle  or  anterior  third  are 
seldom  described  as  amaurotic  eyes.  H.  F. 
Hansell.] 

Amaurosis     in     Brain     Disease. — 

Tumors  or  other  organic  changes  in 
the  brain  by  which  the  optic  tract  is 
directly  compressed  or  the  ventricular 
fluid  is  forced  into  the  optic  nerve 
sheaths  will  produce  blindness.  The 
process  is  a  mechanical  one.  In  the 
former  the  optic  nerve  fibers  in  the 
tracts  are  directly  compressed  and 
deprived  of  their  function;  in  the 
latter,  the  optic  nerve  is  surrounded 
by  fluid  contained  within  a  sac  of 
only  moderate  distensibilit}^  The 
gradually  induced  compression  of  the 
nerve    induces    arterial    anemia    and 


venous  congestion  of  the  nerve-head 
and  retina,  which  is  soon  followed  by 
serous  and  solid  exudation  into  the 
distal  extremity  of  the  nerve.  Finally 
the  optic  nerve  fibers  become  atro- 
phied from  stoppage  of  circulation 
and  pressure  of  exudation.  The  loss 
of  vision  may  commence  in  the  pe- 
riphery of  the  field  and  advance  by 
slow  stages  toward  the  center  until 
finally  the  entire  field  is  wiped  out ; 
or,  as  may  be  the  case  in  apoplexy,  a 
section  of  the  field,  one-half,  one- 
quarter,  or  less,  or  the  region  about 
the  fixation  point  and  including  it,  is 
suddenly  lost.  Continuation  or  ex- 
tension of  the  brain  lesion  will  be  fol- 
lowed by  loss  of  the  entire  visual 
field. 

Amaurosis  in  Nephritis.— Disturb- 
ance of  vision  may  be  caused  by 
hemorrhage  or  edema  into  the  cere- 
bral centers,  by  pressure  upon  the 
chiasm  or  tracts,  or  by  the  action  of 
the  poison  of  uremia,  by  which  the 
brain  functions  are  held  in  abeyance. 
In  the  first  and  second  it  may  affect 
one  or  both  eyes  and  be  partial  or 
complete.  In  the  third  it  comes  on 
rapidly,  involves  both  eyes,  and  dis- 
appears in  a  few  hours  or  in  a  day  or 
two.  There  are  no  ophthalmoscopic 
changes  visible  in  the  retinal  circula- 
tion or  structural  alterations  in  the 
nerve  or  retina.  The  blindness  is 
strictly  cerebral.  In  the  early  stages 
of  hemorrhage  or  edema  the  eye- 
g'rounds  are  normal;  later  they  show 
the  signs  of  intracranial  pressure.  In 
a  man  who  died  twelve  hours  after 
cerebral  hemorrhage  and  who  was 
unconscious  from  the  time  of  the  at- 
tack until  his  death,  the  ophthalmo- 
scope showed  only  moderate  dilatation 
and  tortuosity  of  the  veins.  These 
forms    of    amaurosis    are    not    to    be 


AMAUROSIS    (HANSELL). 


593 


confounded  with  the  amblyopia  of 
albuminuric  retinitis,  in  which  the 
vision  is  aiTected  in  several  ways;  by 
edema  of  the  nerve-head,  edema  of 
the  retina,  hemorrhage  in  the  foveal 
region,  and  patches  of  degeneration  of 
that  area.  The  diagnosis  may  be  at 
once  established  by  the  Ophthalmo- 
scope. 

Amaurosis  in  Hysteria. — Neuroses, 
the  result  of  an  unknown  derange- 
ment of  the  nervous  system  originat- 
ing within  the  body  or  of  traumatism, 
may  reduce  or  altogether  destroy 
temporarily  the  visual  power  in  one 
or  both  eyes,  rarely  the  latter.  The 
traumatism  may  be  ocular  or  involve 
any  other  part  of  the  body.  In  order 
to  induce  blindness  or  even  amblyopia 
the  causative  disease  or  injury  must 
affect  an  individual  of  peculiar  or  sus- 
ceptible organization  and  makes 
manifest  a  tendency  toward  magnifi- 
cation of  trifles  for  the  sake  of  bring- 
ing into  prominence  the  ego  or  for 
the  sake  of  imposition.  In  traumatic 
cases  the  diagnosis  between  hysteri- 
cal amaurosis  and  malingering  is  not 
always  easy.  Both  offer  no  evidence 
externally  or  internally  in  the  eye  of 
any  mark  of  injury  or  disease  suffi- 
cient to  account  for  the  symptoms. 
In  hysteria  the  well-known  stigmata 
may  be  found — tubular  field,  transient 
and  recurring  ocular  parah^ses,  re- 
versal of  the  color  field,  well-defined 
patches  of  localized  anesthesia  of  the 
skin,  inexplicable  and  transient  pains 
distributed  anywhere  and  everywhere 
in  the  body  and  created  by  cleverly 
directed  interrogation.  The  majority 
of  the  subjects  are  women  who  are 
more  or  less  mentally  unbalanced  by 
disease  of  the  sexual  organs  or  by 
physical  or  mental  idleness.  The  ma- 
lingerer is  usually  a  man  who  resorts 


to  the  excuse  of  blindness  in  order  to 
avoid  unpleasant  or  dangerous  duty 
or -to  collect  damages  from  a  rich  cor- 
poration. The  symptoms  of  hysterical 
amaurosis  are  altogether  subjective 
and  of  cerebral  origin.  The  eyes 
cannot  be  held  responsible. 

Commonly,  in  the  recorded  cases, 
there  have  been  other  manifestations 
of  hysteria,  but  amaurosis  may  be 
the  sole  expression  of  this  disorder. 
Unilateral  hysterical  amaurosis  occurs 
rather  more  rarely  than  the  bilateral 
form,  according  to  Kron,  and  offers 
distinctive  different  diagnostic  problems. 
But  bilateral  hysterical  amaurosis  is 
almost  as  rare  an  affection.  The  writer 
describes  such  a  case  which  presents 
several  interesting  features :  The  sud- 
den blindness,  and  later  sudden  meno- 
plegia  with  loss  of  pain  sense,  the  loss 
of  stereognosis  sense  in  the  affected 
member  due  apparently  to  loss  of  mus- 
cular and  articular  sensation,  and  con- 
tracted visual  fields  of  the  tubular 
variety.  The  author  reports  2  other 
cases.  Diller  (Jour.  Amer.  Med. 
Assoc,  Apr.  24,  1909). 

Amaurosis     in     Spinal     Disease. — 

Primary  atrophy  of  the  optic  nerves 
preceding  or  accompanying  disease 
of  the  spinal  cord  and  spinal  nerves 
is  a  common  affection.  It  is  "pri- 
mary" because  it  is  initiated  and 
carried  to  its  finish  without  inflam- 
mation of  the  optic  nerve  visible  to 
the  ophthalmoscope.  There  is  no 
edema  or  exudation.  The  disk  mar- 
gins remain  clear  cut  and  well  de- 
lined.  The  first  noticeable  change  is 
a  loss  of  the  normal  pink  color  on  the 
temporal  half  of  the  papilla  and  a 
diminution  of  the  size  of  both  the 
arteries  and  veins  of  the  retina. 
Gradually  the  vascularity  becomes 
less,  the  nerve  becomes  paler  and 
finally  white,  all  the  fine  vessels 
having  become  absorbed  from  the 
surface.     Contemporaneously  with  the 


1-^ 


594 


AMAUROSIS    (HANSELL). 


atrophic  process  the  vision  declines 
until  complete  amaurosis  results. 
Early  in  the  disease  the  field  for 
colors  is  concentrically  contracted  or 
the  perception  of  green  is  lost,  and 
the  retina  becomes  less  sensitive  to 
light  or  the  optic  nerve  less  capable 
of  transmitting  feeble  stimulation. 
The  affection  is  binocular,  although 
one  eye  is  usually  more  affected. 
Secondary  atrophy,  that  following 
inflammation  of  the  intraocular  end 
of  the  optic  nerve,  presents  entirely 
different  ophthalmoscopic  appear- 
ances, and  no  confusion  need  arise  in 
the  diagnosis  between  the  two  affec- 
tions. The  diseases  of  which  primary 
optic  nerve  atrophy  is  a  prominent 
symptom  are  tabes,  disseminated  and 
lateral  sclerosis,  dementia  paralytica, 
and  paralysis  agitans.  The  pupillary 
and  visual  disturbances  may  precede 
by  many  years  the  development  of 
spinal  affections,  particularly  posterior 
sclerosis,  and  many  of  the  so-called 
idiopathic  cases  really  belong  to  this 
class.  The  writer  believes  this  is  true 
also  of  paralysis  agitans.  He  has  at 
present  a  patient  who  seven  years  ago 
had  incipient  atrophy  of  the  optic 
nerves  with  shallow  excavation  and  for 
the  past  two  years  has  slowly  advancing 
paralysis  agitans. 

Amaurosis  following  Hemorrhage. 
— After  extensive  loss  of  blood  from 
any  cause,  but  especially  from  disease 
of  the  stomach,  intestines,  or  uterus, 
blindness  affecting  both  eyes,  com- 
.mencing  two  or  three  days  after 
the  hemorrhage  and  advancing  rap- 
idly, may  ensue.  The  ophthalmoscope 
shows  marked  ischemia  of  the  retina 
with  low-grade  edema  of  the  nerve- 
head.  The  blindness  may  be  complete 
and  permanent,  terminating  in  optic 
nerve   atrophy;   or,   in   an   individual 


with  good  recuperative  power  or  when 
the  loss  of  blood  has  been  moderate, 
restoration  of  sight  may  be  complete. 
Amaurosis  in  Pregnancy. — Toward 
the  completion  of  the  term  of  preg- 
nancy or  during  confinement,  vision 
may  be  entirely  suspended  in  both 
eyes  for  some  hours  or  days.  The 
amaurosis  is  usually  associated  with 
convulsions  or  other  signs  of  puer- 
pural  septicemia.  It  should  be  re- 
garded as  a  strong  indication  of 
intense  and  general  poisoning.  The 
fundus  either  shows  no  deviation 
from  the  normal  or  the  retinal  veins 
are  distended  and  dark  in  color,  the 
nerve-head  is  slightly  edematous,  and 
an  occasional  hemorrhage  is  found  in 
the  retina.  After  safe  delivery,  vision 
rapidly  returns  and  the  eyes  are 
restored  to  their  previous  condition. 
Atrophy  of  the  nerve  and  permanent 
amaurosis  as  a  result  of  pregnancy 
alone  have  not,  as  far  as  the  writer 
knows,  been  described,  yet  he  has 
seen  cases  in  which  no  other  cause  for 
the  blindness  could  be  assigned. 

Case  of  amaurosis  gradually  develop- 
ing in  the  course  of  pregnancy.  The 
first  signs  of  optic  neuritis  were  noted 
about  the  fourth  month;  both  eyes  were 
affected  and  external  causes  could  be 
excluded.  The  optic  nerve  was  atro- 
phied when  the  patient  was  first  seen 
and  the  indications  for  interruption  of 
the  pregnancy  were  beyond  question. 
Sight  began  to  improve  at  once,  and 
within  two  weeks  vision  was  restored 
in  the  right  eye.  The  other  eye  was 
first  involved,  and  the  nerve  was 
atrophic  beyond  relief.  The  woman 
was  a  multipara  of  Zl ,  with  8  children, 
and  the  author  deem^ed  it  necessary  to 
insure  future  sterility  by  an  operation 
on  the  tubes.  The  case  confirms  anew 
the  importance  of  immediate  interrup- 
tion of  the  pregnancy  in  case  of  optic 
neuritis  from  this  cause.  Holzbach 
(Zentralbl.   f.   Gynak.,  May  23,   1908). 


AMAUROSIS    (HANSELL). 


595 


Case  of  a  woman  of  34,  with  chronic 
nephritis,  who  in  the  fifth  month  of  her 
seventh  pregnancy  developed  amaurosis 
with  headache  and  detachment  of  the 
retina  on  both  sides.  Abortion  was  in- 
duced and  was  followed  by  retrogres- 
sion of  the  detachment  of  the  retina, 
but  the  atrophy  of  the  optic  nerve 
proved  irreparable.  The  trephining  to 
relieve  the  pressure  on  the  brain  evi- 
dently came  too  late ;  the  pupil  reaction 
was  abolished  by  the  second  day  after 
the  woman  had  entered  the  hospital. 
The  case  teaches  the  importance  of 
emptying  the  uterus  and  of  prompt 
measures  to  reduce  the  intracranial 
pressure  if  vision  is  not  promptly  re- 
stored. Himmelheber  (Miinch.  med. 
Woch.,  Oct.   19,  1909). 

A  form  of  amaurosis  or  amblyopia, 
not  accompanied  by  ophthalmoscopic 
signs,  or,  at  least,  by  none  adequate  to 
account  for  the  condition,  may  super- 
vene during  pregnancy,  parturition,  or 
the  puerperium.  Rarely  it  may  assume 
the  form  of  a  hemianopic  defect  or  of  a 
central  scotoma  in  the  fields  of  vision, 
and  still  more  rarely  of  hemeralopia 
(night  blindness).  It  is  often  associated 
with  such  signs  and  symptoms  of 
toxemia  as  headache,  edema,  eclampsia, 
and  scanty  urine  containing  albumin, 
casts,  and  blood.  It  appears  to  form 
one  of  the  rarer  manifestations  of 
toxemic  poisoning.  It  is  not  proved  to 
be  dependent  upon  uremia,  although  it 
has  usually  been  confused  with  so-called 
"uremic  amaurosis."  Recovery  occurs, 
as  a  rule,  completely  within  a  few  hours 
or  days.  Sydney  Stephenson  (Ophthal- 
moscope, March,  1910). 

Amaurosis  from  Fracture  of  the 
Skull. — Numerous  cases  have  been 
recorded  of  complete  blindness  of 
both  eyes  some  months  after  a  trau- 
matism of  the  skull.  The  common 
lesion  is  fracture  at  the  apices  of  the 
orbits  with  or  without  involvement  of 
other  bones  at  the  base.  Hemorrhage 
from  rupture  of  a  large  blood-vessel 
either  anteriorly  at  the  base  or  in- 
volving the  basal  or  cortical  centers 


of  vision,  a  frequent  complication  of 
fracture  of  the  skull,  will  destroy 
vision. 

In  the  latter  lesion  the  amauro- 
sis is  more  rapid  in  its  onset  and 
temporary.  Absorption  of  the  blood 
is  followed  by  gradual  return  of  vision 
unless  the  nerve  structures  have  been 
destroyed  by  the  insult  or  by  press- 
ure. 

Transient  blindness  from  contusion 
of  the  skull  in  a  boy  o!"  12  who  had 
been  run  over  by  an  automobile,  brain 
substance  protruding  from  a  gash  in 
skull.  The  boy  was  unconscious  at 
first  and  was  blind  when  he  roused,  the 
amaurosis  being  complete  with  no  per- 
ception of  light.  Vision  then  grad- 
ually returned  and  by  the  third  day  was 
normal  and  it  has  persisted  so  to  date, 
the  other  injuries  soon  healing.  C. 
Hirsch  (Deut.  med.  Woch.,  August  4, 
1910). 

Congenital  and  Hereditary  Amau- 
rosis.— Infants  born  with  ocular  or 
cerebral  defects,  such  as  buphthalmus, 
microphthalmus,  or  other  deformities, 
or  "amaurotic  family  idiocy,"  by 
which  the  essential  parts  of  the  eye 
or  brain  are  wanting  or  so  disturbed 
that  function  is  absent,  are  hope- 
lessly blind.  Hereditary  optic  nerve 
atrophy,  transmitted  usually  to  males 
through  the  female  line,  appears  sud- 
denly between  the  twentieth  and 
thirty-fifth  year  as  a  loss  of  central 
vision.  The  scotoma  increases  and 
the  periphery  of  the  field  becomes 
contracted  until  the  patient  is  per- 
manently and  totally  amaurotic. 

Having  found  in  the  family  history  of 
an  inmate  of  the  Missouri  School  for 
the  Blind  the  presence  of  cataract  in  all 
the  members  of  the  family  for  at  least 
five  generations,  the  writer  after  receiv- 
ing the  opinions  of  152  oculists  con- 
cludes as  follows :  1.  All  whose  life 
work  brings  them  into  relationship  with 
the  blind  should  be  aware  of  the  dan- 


596 


AMBLYOPIA    (HANSELL). 


gers  connected  with  the  marriage  of  a 
blind  person.  2.  The  blind  themselves 
should  be  warned  of  the  danger  to 
their  children  in  case  of  marriage.  3. 
A  distinction  must  be  made  between 
hereditary  and  non-hereditary  forms  of 
blindness.  4.  Legal  assistance  should 
be  invoked  to  prevent  blind  people 
from  marrying.  5.  This  law  should 
apply  only  to  those  cases  of  blindness 
in  which  heredity  has  been  proved. 
With  the  exception  of  glaucoma  and 
cataract,  these  diseases  usually  mani- 
fest themselves  at  or  before  the  marry- 
ing age.  6.  A  law  compelling  every 
person  to  have  an  oculist's  certificate 
before  marriage,  though  idealistic, 
would  be  impracticable.  7.  The  general 
public  should  be  educated  in  the  dan- 
gers arising  from  hereditary  blindness. 
C.  Loeb  (Annals  of  Ophthal.,  Jan., 
1909). 

Howard  F.  Hansell, 

Philadelphia. 

AMBLYOPIA.  —  DEFINITION. 

— The  word  "amblyopia"  signifies, 
without  specializing  the  cause,  that 
the  acuity  of  vision  is  below  the  nor- 
mal. The  degree  of  the  loss  of  vision 
is  not  suggested  by  the  word  itself, 
nor  has  there  been  any  attempt,  as 
far  as  I  am  aware,  to  define  its  lim- 
itations. It  has  been  inherited  from 
the  preophthalmoscopic  times,  when  the 
two  words  amblyopia  and  amaurosis 
were  commonly  used,  the  former  to 
mean  dull  vision  and  the  latter,  blind- 
ness. 

[Today  we  seldom  hear  of  amaurosis,  but 
we  have  tenaciously  held  to  amblyopia.  Its 
use  is  convenient,  but  unless  preceded  by  a 
descriptive  adjective,  such  as  toxic,  hysterical, 
its  meaning  is  indefinite  and  vague.  The 
sense  in  which  the  word  is  properly  used  is 
to  express  partial  loss  of  vision  due  neither 
to  dioptric  abnormalities  nor  to  visible  or- 
ganic lesions,  or,  as  expressed  by  the  older 
writers,  "amblyopia  without  ophthalmoscopic 
appearances."  It  is,  therefore,  not  a  disease, 
but  a  symptom,  and  is  due  to  many  causes. 
H.  F.  Hansell.] 


The  varieties  of  amblyopia  are 
usually  classified  into  organic  from 
toxic  and  intracranial  causes,  functional, 
exanopsia  (disuse,  non-use,  argam- 
blyopia)  ;  hysterical,  simulated,  and 
from  exhaustion. 

Toxic  Amblyopia. — The  ingestion 
of  or  absorption  into  the  system  through 
the  lungs,  intestinal  tract,  or  skin,  of 
large  quantities  of  certain  substances 
without  adequate  elimination,  or  of 
small  quantities  in  the  case  of  some 
susceptible  organisms,  will  produce  a 
loss  of  vision  varying  in  degree  from 
slight  up  to  total  blindness.  The  com- 
monest agents  are  alcohol  and  tobacco 
in  combination,  lead,  quinine,  methyl 
alcohol,  Jamaica  ginger,  coffee,  mer- 
cury, phosphorus,  chloral,  opium,  ergot, 
the  salicylates,  ptomaines.  The  sight  is 
affected  by  these  substances  in  several 
ways — by  altering  the  constituency  of 
the  blood  and  lessening  its  nutritive 
value  to  the  ocular  structures ;  by  excit- 
ing disease  of  the  retinal  nerve-cells 
leading  to  degeneration  of  the  cells  and 
of  the  optic-nerve  fibers  connecting 
them  with  the  brain-centers  and  induc- 
ing structural  changes  in  the  centers 
for  vision.  The  amblyopia  may  be 
acute,  as  in  quinine  and  methyl  alcohol, 
or  chronic,  as  in  tobacco  and  alcohol 
poisoning. 

The  symptoms  common  to  the  chronic 
form  are : — 

Loss  of  T^ision. — The  deterioration 
is  gradual  and  is  usually  neglected  by 
the  patient  until  the  ability  to  read  is 
diminished  or  abolished.  Examina- 
tion shows  that  vision  has  fallen  to 
one-half  or  more  for  distance  and  near 
and  is  not  to  be  improved  by  glasses. 
The  patient  complains  of  a  bluish-gray 
smoke  or  mist  constantly  before  the 
eyes,  and  of  partial  night-blindness.  He 
has  no  pain  and  rarely  phosphenes  or 


AMBLYOPIA    (HANSELL). 


597 


other  signs  of  irritation  of  the  retina 
or  nerve. 

Central  scofofiia,  either  relative  (col- 
ors only)  or  absolute.  Early  in  the 
affection,  probably  contemporaneous 
with  the  beginning  of  the  deterioration 
of  vision,  the  perception  for  green  in 
the  small  region  of  the  field  controlled 
by  the  fovea  centralis  is  lost.  Then 
follows  the  perception  for  red  and 
possibly  blue.  The  scotoma  may  be 
confined  to  these  colors.  Should  the 
disease  advance,  the  scotoma  becomes 
absolute,  the  perception  of  all  objects 
being  lost  in  an  area  of  about  10° 
from  the  fixation  point.  The  periph- 
ery of  the  field  retains  its  normal 
dimensions  until  the  onset  of  optic 
nerve  atrophy,  when  it  undergoes  a 
concentric  narrowing. 

Papilla  Changes. — The  ophthalmo- 
scope shows  in  nearly  all  instances  a 
whitening  of  the  temporal  half  of  the 
papilla,  with  retention  of  the  normal 
coloring  and  vascularity  of  the  nasal 
half.  The  retina  and  choroid  are  un- 
changed. Even  the  macula,  the  point 
of  the  fundus  which  is  symptomatically 
most  involved,  appears  healthy.  In 
about  one-third  of  the  cases  the  optic 
disk  is  slightly  hyperemic  early  in  the 
disease  and  the  vessels  on  the  disk 
are  veiled,  reflecting  the  earliest  signs 
of  optic  neuritis. 

Acute  poisoning  from  absorption  of 
methyl  alcohol,  quinine,  pure  spirits, 
etc.,  causes  sudden  and  complete  blind- 
ness, even  to  the  loss  of  perception  of 
light.  The  action  of  the  poison  may  be 
sudden  or  cumulative.  A  man  of  35 
was  exposed  by  the  nature  of  his  occu- 
pation to  the  fumes  of  varnish.  Ele 
absorbed  them  through  the  lungs  and 
the  skin  of  the  hands  and  arms.  Feel- 
ing in  his  usual  good  health  when  he 
went  to  bed,  he  was  awakened  several 


hours  later  by  some  cause  unconnected 
with  his  eyes  and  discovered  he  was 
totally  blind.  Examination  of  his  eyes 
the  following  day  disclosed  excessive 
anemia  of  the  disks.  The  arteries  and 
veins  of  the  retina  were  invisible  a 
short  distance  from  the  nerve-head.  A 
boy  of  19  drank  an  unknown  quantity 
of  "white  whisky"  (95  per  cent,  alco- 
hol). He  was  blind  the  next  morning 
and,  except  for  the  temporary  return 
of  perception  of  light  lasting  a  few 
days,  remained  blind.  The  ophthalmo- 
scopic appearances  were  similar  to 
those  in  the  former  case.  The  promi- 
nent symptoms  of  acute  toxic  amblyopia 
are  illustrated  by  both  cases :  Sudden 
and  complete  blindness,  partial  tempo- 
rary recovery,  ischemia  followed  by 
atrophy  of  the  optic  nerves  and  retinas, 
and  permanent  blindness. 

Amblyopia  from  Intracranial 
Causes. — •.In  the  preceding  paragraph 
the  morbid  processes  are  presumed  to 
be  limited  to  the  nervous  mechanism  of 
the  eye,  lying  anterior  to  the  chiasm  or, 
if  they  invade  the  cerebral  tissues,  the 
involvement  is  secondary  and  may  be 
considered  as  a  complication.  In  the 
intracranial  amblyopias  the  original  le- 
sion is  cerebral,  the  secondary  in  the 
optic  nerves  and  retina.  Uremia  of 
Bright's  disease,  of  pregnancy,  and 
of  scarlet  fever  is  a  common  cause. 
The  amblyopia  is  usually  binocular, 
rapid  in  its  course,  and  leads  often 
to  coimplete,  but  temporary  blindness. 
The  prognosis  is  good.  No  changes 
in  the  eye-grounds  commensurate 
with  the  degree  of  loss  of  vision  are 
to  be  seen.  The  retinal  veins  are  dis- 
tended, dark,  and  tortuous,  and  the 
edges  of  the  disk  veiled  by  edema 
of  the  nerve  and  adjacent  retina.  The 
cerebral  vessels  present  a  similar 
condition,    namely,    reduced    supply   of 


598 


Amblyopia  (hansell). 


arterial  blood,  venous  stagnation,  and 
diffused  serous  exudation  into  the  brain 
substance.  The  foreign  elements  con- 
tained in  the  blood  doubtless  are  a  con- 
tributing cause  to  the  disturbed  brain 
functions.  With  the  establishment  of 
free  secretion  of  urine  or  artificially 
induced  active  diaphoresis  the  poison  is 
eliminated  from  the  blood,  the  serum 
absorbed,  and  the  vision  and  cerebration 
restored;  or,  the  kidneys  refuse  to  act, 
the  skin  cannot  be  stimulated,  and  death 
ensues. 

Rarer  forms  of  amblyopia  due  to 
obscure  intracranial  lesions  are  the 
"crossed"  and  the  "hemianopsias." 
Mills  says  (Posey  and  Spiller)  :  "As 
the  fibers  of  the  macular  bundles  are 
undoubtedly  distributed  to  the  pre- 
geniculatum,  complete  destruction  of 
this  body,  or  of  a  special  portion  of 
it,  would  cause -central  amblyopia  of 
the  crossed  variety."  In  the  hemian- 
opic  variety  one-half  of  the  macular 
field  is  lost  and  the  other  half  pre- 
served. Thus  one-half  of  a  word  or 
other  small  object  cloise  to  the  eyes 
is  obscured  and  can  be  seen  only  by 
movement  of  the  ball.  In  explana- 
tion Mills  further  says :  "A  strictly 
limited  lesion  of  the  calcarine  cortex  on 
the  one  hand  and  of  the  angular  region 
on  the  other  may  cause  blindness  in 
half  of  the  macular  field  of  the  cor- 
responding sides." 

Hysterical  Amblyopia. — The  fea- 
tures characteristic  of  this  affection  are 
partial  or  complete  blindness,  monocu- 
lar or  binocular,  without  discoverable 
changes  in  the  ocular  structures  or 
signs  in  the  eye  or  elsewhere  in  the 
body  of  organic  disease  of  the  brain  or 
nervous  system.  The  loss  of  vision 
may  arise  spontaneously,  or  appear  at 
the  termination  of  an  attack  of  general 
hysteria,  or  be  due  to  a  slight  trauma- 


tism to  the  eye  or  head.  The  trau- 
matism is,  as  a  rule,  slight  and  out 
of  all  proportion  to  the  seriousness  of 
the  subsequent  complaints.  Amblyopia 
may  be  the  only  ocular  symptom  or  it 
may  be  complicated  by  ptosis,  recession 
of  the  near-point,  pupillary  inequalities, 
or  disturbances  in  the  field  of  vision. 
The  alteration  in  the  size  and  form  of 
the  field  presents  three  possible  fea- 
tures :  concentric  contraction,  which  is 
not  in  the  least  characteristic  of  hys- 
teria ;  reversal  of  the  normal  limits  of 
the  color  fields,  and  the  tubular  field. 
Traumatic  cases  recover  promptly  and 
wholly  after  the  cause,  for  instance  a 
suit  for  damages,  is  removed.  Cases  of 
spontaneous  origin  and  those  dependent 
upon  functional  derangements  of  the 
nervous  system  are  more  persistent, 
often  recur,  continue  weeks  and  months, 
and  recover  only  upon  the  restoration 
to  health  of  the  inclividual.  It  must  not 
be  forgotten  that  blindness  without 
ophthalmoscopic  findings  or  evidence 
of  disease  of  the  cerebrospinal  system 
may  not  always  be  diagnosed  as  hys- 
terical, and  that  it  may  have  an  organic 
cause  to  become  manifest  in  time.  To 
make  the  diagnosis  positive  it  should  be 
associated  with  at  least  some  of  the 
well-known  stigmata  of  hysteria. 

Simulated  Amblyopia. — The  differ- 
ential diagnosis  between  simulated  and 
hysterical  amblyopia  is  rendered  diffi- 
cult by  the  similarity  of  the  two  affec- 
tions and  because  both  occur  in  the 
same  class  of  patients,  the  neurotic  and 
those  of  hypersensitive  organizations. 
Pretended,  feigned,  or  simulated  blind- 
ness is  found  among  recruits  for  the 
army  and  navy  services,  those  who  wish 
to  escape  positions  in  which  danger  or 
punishment  may  be  incurred,  and  those 
who  wish  to  create  false  impressions 
and    exaggerated    estimates    of    their 


Amblyopia  (hanselL). 


599 


physical  disabilities,  especially  in  law- 
suits for  damages.  Simulated  am- 
blyopia of  both  eyes  is  rare  and  detec- 
tion difficult.  Reliance  must  l)c  placed 
on  the  action  of  the  pupils  and  the  want 
of  relation  between  tiie  apparently  nor- 
mal eyes  antl  the  symptoms.  The  mo- 
nocular form,  however,  may  be,  as  a 
rule,  easily  detected.  The  ophthalmo- 
scope shows  clear  media  and  healthy 
eye-grounds ;  a  strong  spherical  lens 
placed  before  the  sound  eye  will  prevent 
accurate  vision  in  that  eye  beyond  the 
focal  distance  of  the  glass ;  a  prism  of 
5°,  base  down  or  up,  will  give  vertical 
diplopia;  a  prism  of  10°,  base  out,  will 
cause  a  manifest  rotation  of  the  eye 
inward,  unconsciously  made  to  fuse  the 
horizontally  induced  double  images ;  a 
lead  pencil  placed  before  the  sound  eye 
will  not  interrupt  reading;  the  pupils 
respond  to  light  and  convergence  almost 
uniformly.  The  tests  will  more  suc- 
cessfully deceive  the  patient  into  admit- 
ting visual  power  in  the  assumed  blind 
eye  if  his  attention  is  directed  by  them 
to  the  sound  eye.  Radiography  is  also 
valuable  in  the  diagnosis.  An  individ- 
ual may  claim  that  the  blind  eye  con- 
tains a  fragment  of  glass  or  other 
foreign  material  impervious  to  the  rays. 
In  such  cases  a  shadow  is  cast  on  the 
plate  when  the  claim  is  true.  In 
trolley  accidents  it  frequently  happens 
that  the  glass  of  the  doors  or  windows 
is  shattered  and  the  hysterical  or  fraud- 
ulently inclined  passenger  asserts  that 
he  was  blinded  by  the  entry  and  reten- 
tion in  his  eye  of  glass.  Examination 
with  the  ophthalmoscope  cannot  inva- 
riably exclude  the  presence  of  the 
foreign  body,  particularly  when  it  has 
lodged  in  the  ciliary  region  or  when 
the  media  are  clouded. 

Amblyopia  Exanopsia. — From  con- 
genital defects  in  the  ocular  structures, 


such  as  cataract,  polar  and  lamellar; 
coloboma  of  the  lens  or  uveal  tract; 
persistent  pupillary  membrane;  albi- 
nism. Rays  of  light  are  obstructed  in 
their  passage  through  the  eye  by  the 
opaque  media,  they  are  not  clearly 
focused  on  the  retina  by  reason  of 
irregular  refraction,  or  they  fall  upon 
insensitive  retinas  or  those  unsupported 
by  choroidal  pigment.  In  these  cases  it 
is  probable  that  early  in  life  the  retinal 
centers  in  the  brain  are  active  and  do 
not,  either  by  disease  or  congenital 
anomaly,  contribute  to  the  blindness. 
The  cataracts  may  be  removed  and 
vision  restored  when  the  operations  are 
performed  at  an  early  age.  Later,  when 
the  brain-centers  have  been  trained  and 
the  habits  of  special  sense  perception 
have  been  formed,  operations,  although 
surgically  successful,  do  not  materi- 
ally improve  vision. 

From  Defects  of  Refraction. — In 
grades  of  hyperopia  from  2  D.  to  5  D. 
in  childhood,  binocular  vision  may  early 
become  unattainable.  The  child  uncon- 
sciously, in  order  to  obtain  good  vision, 
makes  extraordinary  claims  on  the  ac- 
commodation. But  the  ciliary  muscle 
(accommodation)  is  supplied  by  nerve 
power  by  the  third  or  motor  oculi 
nerve,  which  also  supplies  the  muscles 
of  convergence.  Therefore,  excessive 
stimulation  of  accommodation  or  that 
surpassing  the  normal  relation  between 
accommodation  and  convergence  com- 
pels a  proportionately  equal  degree 
of  convergence.  Since  both  eyes  can- 
not converge  simultaneously  in  dis- 
tant vision,  one  eye  assumes  the 
abnormal  convergence  and  the  other 
eye  is  used  for  fixatiion.  Both  eyes 
retain  their  normal  power  of  rotation, 
but  each  becomes  in  a  sense  inde- 
pendent of  the  other :  the  one  is  used 
for    seeing;   the   other    squints.     The 


600 


AMENORRHEA    (MONTGOMERY). 


former  has  been  the  better  eye  from 
the  beginning,  either  by  reason  of 
less  error  of  refraction  or  more  per- 
ceptive retina.  The  latter  gradually 
becomes  amblyopic  from  disuse.  The 
retina  loses  its  sensibility,  the  optic 
nerve  its  conductility,  and  the  cerebral 
centers  their  function.  In  some  chil- 
dren no  reason  can  be  assigned  for 
preference  of  one  eye.  The  error  of 
refraction  may  be  no  greater  and  the 
rotatory  power  no  less  in  the  squinting 
than  in  the  fixing  eye.  Here  we  must 
assume  that  the  fault  lies  in  the  retina, 
nerve,  or  brain.  Improvement  of  vision 
may  be  obtained  by  the  forced  use  of 
the  eye  and  the  compulsory  activity  of 
the  cerebral  center,  but  vision  equal  to 
that  of  the  non-squinting  eye  is  seldom 
or  never  acquired  unless  the  usefulness 
of  that  eye  is  destroyed  by  accident  or 
disease.  Habit  and  the  cultivation  of 
the  visual  apparatus  that  accrues  from 
habit  can  not  be  ignored.  Should, 
however,  the  treatment  for  defective 
vision  be  instituted  very  early,  before 
anesthesia  of  the  nervous  apparatus  of 
the  squinting  eye  has  developed,  an 
appreciable  benefit  may  be  gained  by 
the  use  of  the  amblyoscope,  closure  of 
the  fixing  eye  by  bandage,  or  atro- 
pinization  of  that  eye. 

Amblyopia  from  Exhaustion.. — Am- 
blyopia in  consequence  of  excessive 
indulgence  in  coitus  or  masturbation 
has  been  recorded.  It  is  a  purely 
nervous  affection.  Upon  removal  of 
the  cause  and  the  administration  of 
strychnine  the  cure  is  generally  rapid 
and  complete.  Sudden  loss  of  blood  in 
large  quantities,  occurring  sometimes  in 
intestinal  ulceration,  after  delivery  of 
the  child  in  confinement,  rupture  of 
blood-vessels  by  ulceration  or  accident, 
may  be  followed  in  a  few  hours  by 
temporary  loss  of  vision.   The  ambly- 


opia becomes  permanent  only  in  cases 
of  degeneration  of  the  ganglion  cells 
of  the  retina  or  of  the  fibers  of  the 
optic  nerve. 

Howard  F.  Hansell, 

Philadelphia. 

AMENORRHEA.  —  D  E  F I N I  - 
TION. — Absence  of  the  menstrual  flow 
in  women  of  a  suitable  age  who  are 
not  pregnant.  Suppression  of  menses, 
the  menstruation  having  ceased  through 
some  local  or  remote  disorder,  is  also 
termed  amenorrhea. 

VARIETIES.  —  Amenorrhea  may 
be  complete,  when  the  menstruations  will 
have  completely  ceased;  comparative, 
when  it  appears  occasionally;  primary, 
when  the  menstruation  has  not  pre- 
sented itself  at  the  age  of  puberty  nor 
subsequently;  secondary,  when  transi- 
tory or  accidental,  or,  having  already 
appeared,  the  menstruation  ceases. 

SYMPTOMS.— No  other  symptom 
than  absence  of  the  menstruation  may 
be  present,  or  the  monthly  flow  may 
be  absent  and  the  general  attendant 
phenomena  usually  preceding  men- 
struation occur.  Frequently  the  pa- 
tient complains  of  headache,  heat- 
flashes,  fever,  nausea  and  vomiting, 
and  heaviness  in  the  abdomen.  Con- 
comitant nervous  disorders  may  form 
the  basis  of  acute  manifestations, 
hysterical  especially.  When  the 
amenorrhea  is  due  to  obstruction, 
v/hether  congenital  or  acquired,  the 
patient  does  not  experience  severe 
pain,  but  rather  a  continuous  dull 
aching  in  the  pelvis  and  over  the 
sacrum,  aggravated  at  the  periods 
when  the  menstruation  should  occur 
by  .the  symptoms  above  mentioned, 
known  as  menstrual  molimina. 

Pure  suppression  of  the  menstrua- 
tion   rarely    causes    symptoms,    espe- 


AMENORRHEA    (MONTGOMERY). 


601 


cially  when  the  impcndinsa:  general 
disorder  is  I'he  cause  of  the  amenor- 
rhea. 

Case  of  complete  amenorrhea  in  a 
Greek  woman  of  abot  40  years  with  no 
evidence  of  defects  of  any  kind,  and 
with  good  average  intelligence,  who 
complained  of  minor  nervous  troubles 
which  accompany  menopause.  The 
woman  never  had  menstruated ;  she  had 
given  birth  to  11  children,  5  of  whom 
were  living  at  time  of  examination ;  the 
grandmother  of  the  patient  had  never 
menstruated;  "the  mother  of  the  patient 
had  menstruated  only  once  in  every 
6ne  or  two  j-ears.  Of  the  patient's 
children,  1,  a  girl  of  14  years,  had  not 
yet  menstruated.  The  patient  herself 
was  married  at  the  age  of  15  and  gave 
birth  to  her  last  child  four  years  ago. 
Patient  further  said  she  had  never  had 
symptoms  of  a  menstrual  molimen  of 
any  sort  whatever,  no  knowledge  of 
when  her  menstrual  time  might  be  due, 
no  malaise,  no  pain,  nothing,  in  fact, 
saying  that  she  simply  lived  like  a  man 
and  didn't  know  what  it  was  to  be  sick. 
A.  R.  Hoover  and  J.  K.  Marden  (Surg., 
Gynec.  and  Obstet,  March,  1911). 

The  menstrual  flow  may  be  sub- 
stituted by  a  profuse  leucorrhea  which 
is  thick,  viscid,  and  of  a  yellow  or 
greenish-yellow  color.  Remote  symp- 
toms may  present  themselves,  doubtless 
of  reflex  origin. 

ETIOLOGY.— The  discussion  of 
the  causes  of  amenorrhea  is  rendered 
difficult  by  our  want  of  knowledge  of 
the  forces  which  produce  the  periodi- 
cal recurrence  of  menstruation.  Pri- 
mary amenorrhea  is  generally  due  to 
imperfect  or  insufficient  develop- 
ment. In  cold  countries  the  individ- 
ual matures  more  gradually  and  the 
menstrual  flow  appears  later  than  in 
warm  countries,  where  development 
is  rapid,  but  where,  also,  w^omen  enter 
stages  of  decrepitude  at  an  earlier 
date.  Anatomical  imperfections  and 
anomalies,  the  absence  of  any  of  the 


genital  organs,  or  a  rudimentary  or 
infantile  uterus  may  thus  account  for 
the  total  absence  of  menstruation. 
Imperforate  hymen  is  a  frequent, 
though  easily  recognized,  cause. 

Whether  we  ascribe  the  periodi- 
cal occurrence  of  menstruation  to 
nervous  irritation,  to  the  influence  on 
the  mucous  membrane  of  the  uterus 
of  a  superabundance  of  lime  salts  in 
the  blood  or  to  the  chemical  influence 
through  the  blood  of  a  secretion  of 
the  corpus  luteum,  the  causes  of 
amenorrhea  can  be  divided  into  four 
classes : — 

Nervous  Disorders. — Grief,  anxiety, 
fright,  and  anger  are  as  many  possible 
primary  causes,  especially  if  the 
patients  are  poorly  fed.  According  to 
Bloom,  probably  not  less  than  33  per 
cent,  of  women  emigrants  under  30 
years  of  age  suft'er  from  suppressed 
menstruation  after  a  sea-voyage.  Many 
have  abdominal  distention,  and  not  in- 
frequently girls  have  been  innocently 
charged  with  being  pregnant.  Obsti- 
nate constipation  is  a  common  symptom. 
The  true  etiology  is  largely  psychical 
and  neurotic. 

Series  of  cases  which  present  certain 
well-defined  clinical  features.  These 
prominent  characteristics  are:  (1)  di- 
minished or  arrested  menstruation;  (2) 
local  symmetrical  imperfect  oxygena- 
tion of  the  blood  of  the  extremities, 
especially  the  arms  and  hands — a  con- 
dition known  as  "Raynaud's  phenom- 
ena," and  (3)  pulmonary  tuberculosis. 
The  presence  of  any  single  one  of  these 
symptoms  in  patients  is  observed  every 
day,  but  attention  has  not  hitherto  been 
called  to  the  remarkable  association  of 
all  of  these  clinical  features  in  the  same 
individual.  This  trilogy  of  symptoms 
did  not  always  appear  contemporane- 
.  ously  in  any  of  the  patients  who  were 
affected.  In  all  of  them,  when  first  seen, 
the  local  asphyxia  and  the  irregularity 
of  menstruation  were  marked;    in  two 


602 


AMENORRHEA    (MONTGOMERY). 


of  the  patients  pulmonary  tuberculosis 
was  also  coexistent  with  the  other  clin- 
ical features  mentioned,  while  in  two 
other  patients  it  developed  at  a  subse- 
quent period.  J.  W.  Byers  (Lancet, 
Aug.  26,  1899). 

Case  of  a  young  married  woman  who 
found  that,  as  soon  as  she  left  London 
and  went  to  the  country,  her  menstrua- 
tion would  return  at  the  regular  times, 
but  would  not  if  she  remained  in  town. 
By  leaving  town  for  two  days  each 
month  it  was  possible  for  her  to  regu- 
late the  monthly  function.  W.  J.  H. 
Hepworth    (Lancet,  Nov.   10,   1900). 

The   causes    of   primary    amenorrhea 
at  puberty  not  due  to  congenital  atresia 
may  be   distinguished  into  three  varie- 
ties,  viz. :     1.    Cases   without    discover- 
able cause,  in  which  the  genital  organs 
are     apparently    perfectly    normal.      2. 
Those   due   to    some   congenital   defect. 
3.  Amenorrhea  accompanying  some  gen- 
eral disease,  as  diabetes  or  tuberculosis. 
In  the  first,  local  or  general  treatment 
may   cause   appearance   of  the   menses, 
the  prognosis  in  the  other  two  varieties 
being  unfavorable.     The  writer  cites  a 
case    in    which    menstruation    occurred 
after  grafting  of  a  healthy  ovary  from 
another    subject    in    the    uterine    wall. 
V.  le  Larier   (Paris  Thesis;    Zentralbl. 
f.  Gynak.,  Nu.  35,   1905). 
Women  who  either  greatly  fear  or 
greatly     desire     to    become     pregnant, 
newly    married    women,    and    women 
who  are  confined  in  prisons  or  insane- 
asylums  furnish  a  large  proportion  of 
the  cases.     Removal  from  country  to 
city    or    vice    versa,    especially    when 
coupled   with   nostalgia,   is   a   prolific 
cause.    On  general  principles,  change 
in  the  mode  of  living  or  of  climate, 
especially    with    an    intervening    sea- 
voyage,  appears  to  frequently  act  as 
the  etiological  factor. 

Amenorrhea  may  be  an  early  symp- 
tom of  brain  tumor  and  in  acromegaly 
may  precede --  every  other  symptom 
by  several  months  and  be  followed 
by  optic  atrophy. 


General  Affections. — Amenorrhea 
frequently  occurs  after  d,  serious  ill- 
ness, such  as  typhoid  fever,  eruptive 
fevers,  mumps,  pneumonia,  or  during 
the  course  of  any  chronic  disease, 
diabetes,  cancer,  malaria,  at  the  onset 
of  severe  syphilis.  Intoxication  of 
the  system,  as  in  morphinism,  alco- 
holism, and  hydrargyrism,  is  also  a 
recognized  cause.  Syphilis  is  also 
thought  capable  of  causing  amenor- 
rhea. 

Eighteen  cases  in  which  the  morphine 
habit  caused  amenorrhea.  It  is  usually 
complete  and  accompanied  by  loss  of 
sexual  desire,  but  the  functions  are 
re-established  if  the  habit  be  broken. 
Lutaud  (Revue  gen.  de  clin.  et  de  then, 
May  2,  1889). 

Three  cases,  aged  from  28  to  42,  in 
which  amenorrhea  persisting  from  six 
to  eight  years  was  probably  due  to 
syphilis.  They  all  exhibited  character- 
istic symptoms  of  tertiary  syphilis,  and 
were  subjected  to  a  rigid  mercury  and 
iodide  treatment  which  resulted  in  the 
return  of  the  menstrual  flow.  Meirow- 
sky  and  Frankenstein  (Deut.  med. 
Woch.,  Aug.  4,  1910). 

It  may  be  consequent  upon  an  acute 
or  chronic  surgical  affection,  a  blow, 
or  injury.  Luxurious  living  and  want 
of  exercise,  obesity,  and  excessive  in- 
tellectual labor  at  the  period  of 
puberty,  when  not  counterbalanced 
by  fresh  air  and  active  exercise,  may 
retard  the  development  of  the  genera- 
tive organs  and  thus  induce  the 
disorder. 

Blood  Disorders  and  Wasting  Dis- 
eases.— Anemia  and  idiopathic  chlo- 
rosis, pernicious  anemia,  leukemia, 
and  Hodgkin's  disease  are  the  most 
prominent  factors.  The  following 
causes  of  waste— and  directly,  there- 
fore, of  amenorrhea — are  also  to  be 
remembered :  Hemorrhage,  albumi- 
nous   discharges ;    hemorrhage    from 


AMENORRHEA    (MONTGOMERY). 


603 


piles,  scurvy,  purpura,  and  injury,  as 
in  hemophilia ;  hemorrhage  from  the 
stomach,  as  in  gastric  ulcer;  from  the 
lungs,  or  from  the  nose,  and  from  a 
rare  disease  produced  by  a  parasite 
in  the  duodenum:  the  Aiikylostoma 
ditodotalc.  Long-continued  suppura- 
tion, albuminuria,  chronic  diarrhea, 
malignant  ulcers,  tubercular  disease, 
all  impoverish  the  blood,  and  so  may 
cause  anemia.  All  diseases  that 
cause  wasting  of  the  body  finally 
cause  the  menstruation  to  cease. 
Chief  among  these  are  phthisis,  dia- 
betes, caries  of  bone,  protracted  or 
febrile  illness ;  anorexia  nervosa,  the 
patient  wasting  because  she  will  not 
eat;  and  gastric  ulcer. 

The  occurrence  of  menstruation  is 
associated  with  increased  vascular  ten- 
sion ;  hence,  any  condition  which  de- 
creases tension  will  favor  amenorrhea. 

Lesion  of  Genitourinary  Organs. 
— Amenorrhea  may  be  associated  with 
any  lesion  of  the  genital  tract,  though 
less  likely  to  occur  in  inflammatory 
conditions.  Adhesions  from  pelvic 
peritonitis  are  an  occasional  cause  of 
hyperinvolutions  of  the  uterus  and 
amenorrhea  as  a  symptom. 

In  those  cases  where  the  follicular 
stroma  of  the  ovary  has  been  the  seat 
of  an  inflammatory  process  during  the 
infectious  fevers,  the  patient  may  have 
an  amenorrhea  which  may  remain  and 
become  permanent.  Alexander  Simp- 
son  (Practitioner,  Aug.,  1898). 

Atrophy  of  the  ovaries,  senile  atro- 
phy following  pregnancy,  and  cystic 
ovarian  degeneration  are  among  the 
less  common  etiological  factors.  A 
most  complete  examination  of  the 
pelvic  organs,  under  ether,  if  necessary, 
should  be  made  in  such  cases. 

If  menstruation  does  not  appear  at 
the  age  of  puberty,  a  careful  scrutiny 
on  the  part  of  the  physician  is  obliga- 


tory and  imperative.  Case  of  a  young 
woman,  24  years  of  age,  in  whom  the 
amenorrhea  was  of  organic  origin.  A 
dermoid  and  a  suppurating  multilocular 
cyst  were  found  and  removed.  Report 
of  the  pathologist  harmonizes  with  the 
theory  of  the  case,  both  from  physio- 
logical and  pathological  standpoints  :  1. 
That  the  dermoid  had  usurped  the  place 
and  destroyed  the  function  of  the  right 
ovary.  2.  In  one  of  the  cyst-walls  of 
the  multilocular  ovarian  cyst  was  found 
a  shrunken  ovary  the  size  of  a  large 
lima  bean,  and  within  this  ovarian 
stroma  was  found  a  corpus  luteum 
spurium.  To  the  presence  of  this 
ovarian  stroma  was  due  the  womanly 
development,  with  ovulation  and  the 
futile  effort  of  menstruation  and  its 
consequent  suffering.  3.  The  case  dem- 
onstrates the  possibility  of  ovulation 
without  menstruation.  4.  It  leaves 
doubt  whether  the  absence  of  the  ovi- 
ducts was  primary  or  secondary  to  the 
grave  disease  of  the  ovaries,  with  the 
possibility  that  they  were  congenitally 
absent.  ■  S.  It  presents  the  rare  and  ex- 
ceptional condition  of  a  perfectly  de- 
veloped woman  who  had  an  ovary  and 
a  uterus,  who  ovulated,  was  sterile,  and 
never  menstruated,  and  yet  was  ruined 
in  health  by  nature's  effort  to  establish 
an  impossible  normal  function.  W.  B. 
Chase  (Amer.  Jour,  of  Obstet.  and  Dis. 
Women  and  Children,  Oct.,  1898). 

Exposure  to  cold  during  menstrua- 
tion, by  inducing  congestion  of  the 
pelvic  organs,  is  one  of  the  most 
active  exciting  causes,  especially 
when  supplemented  by  a  local  chronic 
disorder.  The  most  important  condi- 
tion with  which  this  disorder  might  be 
confounded  is  pregnancy. 

Case  of  a  healthy  girl,  aged  IS,  who 
had  been  subject  for  a  year  to  gradual 
swelling  of  the  abdomen.  The  period 
had  ceased  for  two  months  only.  The 
breasts  became  hard  and  tense.  The 
hymen  was  intact.  Peritonitis  of  tuber- 
.  culous  origin  suspected.  On  opening 
the  abdomen  an  enormous  cyst,  which 
contained  twenty  pints  of  fluid,  discov- 
ered.    Its  pedicle  was  twisted  and  had 


604 


AMENORRHEA    (MONTGOMERY). 


risen  in  the  parovarium.  On  the  day 
after  the  operation  the  catamenia  re- 
appeared and  the  abdomen  soon  re- 
sumed its  normal  form.  Cortiquera 
(Anales  de  Obst.,  Gine.,  y  Fed.,  Jan., 
1896). 

Case  of  a  young  woman  who  pre- 
sented many  of  the  usual  signs  of 
pregnancy,  including  cessation  of  the  • 
menses,  prominence  of  the  abdomen, 
etc.  On  examination  deposits  of  adi- 
pose tissue  were  found  in  the  abdominal 
walls,  while  the  uterus  was  small — 
smaller,  indeed,  than  usual.  Subsequent 
events  proved  it  to  be  a  case  in  which 
obesity  had  led  to  disturbance,  if  not, 
indeed,  early  appearance,  of  the  men- 
strual function.  Robert  A.  Reid  (Mass. 
Med.  Jour.,  Aug.,  1898). 

Case  of  two   girls,    19  and  21  years 
old,    in    whom    a    dense    circular    band 
high   up   in  the   uterine   cavity   seemed 
to    obstruct    completely    the    escape    of 
the  menstrual  fluid.     No  definite  diag- 
nostic  features   suggested  the  presence 
of    this    unusual    condition.      In    both 
cases    it    was    accidentally    discovered 
when    through    a    vaginal    incision    the 
anterior   uterine    wall    was    split   longi- 
tudinally   and    the    uterine    cavity    laid 
.  open.     In  hoth  cases  the  operation  was 
followed  by  menstrual  discharge.    Rieck 
(Miinch.  med.  Woch.,  March  16,  1909). 
PATHOLOGY.  — A     pathological 
identity  can  hardly  be  attributed  to 
amenorrhea,    owing    to    its    complex 
causes,  the  diverse  physiological  con- 
ditions peculiar  to  the  cases,  and  the 
diathetic     conditions     that     may     be 
present.       The    fact    that     the     true 
nature   of  menstruation   itself   is   un- 
known   adds    another    objection,    and 
it    may    safely    be    said    that    the    pa- 
thology of  amenorrhea  is  that  of  the 
diseases    causing   it,    until    the    local 
disorders  brought  about  by  each  will 
have  been  determined. 

DIAGNOSIS. —  Primary  amenor- 
rhea— that  is,  total  absence  of  men- 
struation— is  usually  due,  as  already 
stated,  to  the  absence  of  one  or  more 


of  the  organs  of  generation.  It  must 
be  distinguished  from  retention  of  the 
menses  due  to  atresia  of  the  cervical 
canal,  of  the  vagina,  or  of  the  vulva. 
In  the  latter  case  no  menstruation  has 
existed,  but  the  general  premonitory 
symptoms  of  menstruation  have  oc- 
curred, though  followed  by  no  men- 
strual flow.  Cases  in  which  one  or 
more  of  the  organs  are  absent  are  not 
very  infrequent,  while  cases  of  im- 
perforate hymen  are  comparatively 
common. 

PROGNOSIS.— Amenorrhea  due 
to  absence  of  any  of  the  organs  is,  of 
course,  incurable.  The  same  may  be 
said  where  the  approach  of  the  meno- 
pause or  other  conditions  point  to  pre- 
mature senility  of  the  uterus,  which 
involves  the  inhibition  of  the  menstrual 
period.  Although  amenorrhea,  when 
due  to  a  serious  chronic  disease,  is 
usually  cured  with  difficulty,  hope  may 
always  be  entertained  when  the  causa- 
tive disorder  is  not  in  itself  a  fatal 
one.  Return  of  the  menstruation  in 
any  chronic  disorder,  when  the  blood 
presents  its  normal  appearance,  is  an 
encouraging  sign. 

TREATMEN  T.— No  woman 
should  be  treated  for  amenorrhea 
until  the  possibility  of  its  being 
caused  by  pregnancy  has  been  elimi- 
nated, if  necessary  by  a  careful  physical 
examination.  Not  infrequently  will 
pregnant  women  desirous  of  escaping 
the  responsibilities  of  maternity  seek  a 
consultation  with  the  hope  that  some 
drug  shall  be  administered  or  instru- 
ment inserted  which  will  terminate  the 
condition. 

Amenorrhea  should  always  arouse 
concern ;  it  may  be  the  first  symptom 
of  acromegaly,  to  which  it  stands  in 
about  the  same  relation  as  ordinary 
goiter  does  to  exophthalmic  goiter,  the 
hypophysis    cerebri    being   so    often   in- 


AMENORRHEA    (MONTGOMERY). 


605 


Volvctl.  Tlie  amcnorrhcic  should  take 
special  pains  to  avoid  chilling,  espe- 
cially of  the  feet,  and  every  catarrhal 
affection  should  be  treated  with  great 
care.  Three  such  patients  in  the 
\vritcr's  practice  had  previous  sinusitis, 
commencing  in  1  case  at  the  time  the 
menses  became  irregular.  Special  care 
should  also  be  paid  to  treatment  of 
syphilis  in  this  connection ;  it  may  be 
injuring  the  hypophysis  even  when 
there  are  no  apparent  manifestations 
elsewhere.  His  experience  further  in- 
dicat-es  that  a  pregnancy  is  liable  to 
aggravate  disease  of  the  pituitary  body. 
He  discusses  the  points  in  which  mor- 
bid amenorrhea  resembles  and  differs 
from  natural  amenorrhea  in  pregnancy 
and  after  the  menopause.  Acromegaly 
is  the  form  of  amenorrhea  in  which 
there  is  sugar  in  the  blood  in  almost 
half  of  the  cases,  and  there  is  hyper- 
trophy of  the  bones  of  the  face.  Rosen- 
berger  (Zentralbl.  f.  innere  Med.,  Feb. 
25,   1911). 

It  should  be  kept  in  mind  that 
amenorrhea  is  a  symptom,  and  its 
cause  be  diHgently  sought  as  a  preHmi- 
nary  measure  to  treatment.  Drugs 
which  are  considered  to  exert  an  in- 
fluence in  promoting  the  menstrual 
flow  are  known  as  emmenagogues, 
and  are  divided  into  two  classes, 
medicinal  and  physiological. 

Severe  physical  shock  or  fright 
sometimes  causes  the  menstruation  to 
return  suddenly. 

When  the  arrest  of  menstruation  is 
due  to  exposure  to  cold,  warm  baths 
and  vaginal  injections,  sinapisms  to 
the  thighs  and  calves  of  the  legs, 
saline  laxative  and  manganese-bin- 
oxide  pills  (2  grains  each),  1  or  2 
after  each  meal,  are  frequently  suc- 
cessful. This  drug  acts  by  increasing 
the  vascularity  of  the  pelvic  organs. 
The  permanganate  of  potassium,  or 
the  lactate,  in  1 -grain  doses  three  or 
four  times  daily,  after  meals,  act  in 
the  same  manner. 


Potassium  permanganate  may  be 
given  daily  until  the  catamenia  appear 
and .  complete  their  course,  when  the 
salt  should  be  discontinued ;  it  should 
be  recommended  four  days  before  the 
access  of  the  next  period,  and  continued 
until  the  flow  ceases.  It  is  useful  in 
girls  who,  on  leaving  the  country  and 
coming  to  town,  suffer  from  arrested 
menstruation ;  also  in  the  amenorrhea 
induced  by  seasickness  and  in  the  case 
of  women,  between  30  and  40,  generally 
married,  who  while  rapidly  increasing 
in  weight  suffer  from  a  diminished 
menstruation.  Potassium  permanganate 
is  given  up  to  1,  2,  or  more  grains  in 
pill  form  thrice  daily,  after  meals.  The 
pills  should  be  made  after  the  following 
formula :  Potassium  permanganate, 
gr.  j ;  kaolin  and  petroleum  cerate,  in 
equal  parts,  q.  s.  Certain  observers 
deny  that  the  permanganate  produces 
abortion,  but  some  cases  of  abortion  ap- 
parently due  to  the  drug  have  been 
observed.      (Practitioner,    Feb.,    1911). 

In  the  amenorrhea  following  sea- 
voyages  the  preparations  of  manganese 
and  oxalic  acid  hold  the  first  place. 

When  the  manganese  preparations 
fail,  santonin,  10-grain  doses  at  bed- 
time, is  especially  valuable  in  chlo- 
rotic  subjects. 

The  general  system  should  be  in- 
vigorated by  attention  to  diet,  sleep, 
and  clothing.  Out-of-door  life,  light 
exercise,  and  sunlight  are  most  im- 
portant. This  is  especially  the  case 
when  there  is  rapidly  increasing  obesity. 
In  the  latter  case  the  diet  should  be 
regulated,  saline  laxatives  adminis- 
tered, or  a  cure  at  Marienbad  recom- 
mended. The  administration  of  thyroid 
extract  is  especially  effective  in  pre- 
mature menopause  from  obesity,  and 
should  be  associated  with  active  exer- 
cise. Stimulation  of  the  ovaries  and 
uterus  by  the  faradic  current  is  espe- 
cially efficient  in  such  cases. 

Cupping  or  scarifying  the  cervix  is 
sometimes  successful.     These  means 


606 


AMMONIA    (SAJOUS). 


increase  the  pelvic  congestion  and 
tend  to  counteract  uterine  or  ovarian 
torpidity. 

Rudimentary  organs  or  atrophy  of 
the  uterus,  if  not  too  great,  should  be 
treated  by  dilatation  of  the  uterus 
with  tents  and  stimulated  by  the 
faradic  current.  The  introduction  of 
a  stem  pessary  which  is  to  be  worn 
for  a  number  of  months  not  infre- 
quently increases  the  growth  of  a 
rudimentary  organ  and  establishes 
the  function  of  menstruation.  Exer- 
cise and  nourishing  food  should  also 
be  given.  Sea-bathing  is  of  assistance 
in  such  cases. 

The  stem  pessary  yielded  excellent 
results  in  the  writer's  hands  in  the 
treatment  of  the  following  special 
types  of  primary  and  secondary  amenor- 
rhea:  1.  In  the  small,  narrow  infan- 
tile uterus  in  otherwise  well-developed 
girls.  2.  In  a  class  of  cases  in  which 
menstruation  has  been  regular  and  nor- 
mal for  years,  but  at  the  age  of  30  or 
35  becomes  scanty  and  skips,  and  is 
painful  in  unmarried  women  who  take 
little  exercise,  but  work  hard  mentally. 
The  uterus  undergoes  premature  at- 
rophy and  is  found  small.  3.  In  women 
who  live  high,  have  good  digestion, 
and  become  fleshy,  the  menstruation 
becomes  scant  and  sometimes  disap- 
pears entirely.  J.  H.  Carstens  (Jour. 
Amer.  Med.  Assoc,  Nov.  20,  1909). 

The  rheumatic  diathesis  occasion- 
ally plays  a  part  as  an  etiological 
factor.  In  such  cases  the  ammoniated 
tincture  of  guaiac,  1  dram  in  milk 
three  times  a  day,  or  the  tincture  of 
colchicum  root,  10  drops  every  three 
hours  until  the  bowels  become  free, 
will  sometimes  restore  arrested  men- 
struation. The  salicylate  of  sodium 
is  also  valuable  in  this  connection. 
Apiol,  4  grains  daily  in  1-grain  pills, 
for  fifteen  days,  has  given  good 
results.     Fuchsin  has  been  highly  rec- 


ommended as  an  effective  drug  in  re- 
establishing the  menstrual  flow. 

Two  cases  in  which  amenorrhea  was 
due  to  pressure  upon  the  uterus,  in  1 
case  by  a  cyst,  in  the  other  by  a  hema- 
tosalpinx. Removal  of  these  obstruc- 
tions was  followed  by  regular  men- 
struation. Rieck  (Miinch.  med.  Woch., 
March  16,  1909). 

Electricity  is  of  great  value,  fara- 
dism,  static  electricity,  galvanism, 
and  galvanic  intra-uterine  pessaries 
being  applicable  according  to  the 
nature  of  the  case. 

Extract  of  cows'  ovaries  has  been 
used  with  success,  but  further  trials 
with  this  agent  are  required  to  estab- 
lish its  actual  value  (see  Animal  Ex- 
tracts: Ovarian  Organotherapy). 

E.  E.  Montgomery, 

Philadelphia. 

AMIDOAGETPHENETIDIN 
HYDROCHLORIDE.  See  Pheno- 
coLL  Hydrochloride. 

AMINOFORM.  See  Hexame- 
thylenamine. 

AMMONIA.  —Ammonia,  chemi- 
cally NH3,  is  made  in  large  quantities 
from  coal  gas  by  heating  the  ammo- 
niacal  liquor  with  calcium  hydroxide, 
thus  conducting  the  gas  formed  through 
tubes  containing  charcoal.  It  may  be 
conveniently  obtained  in  smaller  amount 
by  heating  an  ammonium  salt,  such  as 
ammonium  chloride,  with  dry  caustic 
soda  (sodium  hydroxide)  or  slaked  lime 
(calcium  hydroxide).  It  can  be  formed 
by  the  direct  union  of  nitrogen  and  hy- 
drogen under  the  electric  sparky  and  is 
widely  produced  in  nature  through  the 
putrefaction  of  albuminous  substances. 

PROPERTIES.— Ammonia  is  a 
transparent,  colorless  gas,  having  an  ex- 
tremely pungent  odor  and  acrid  taste. 
It  is  strongly,  alkaline  in  reaction,  and 


AMMONIA    (SAJOUS). 


607 


dissolves  very  readily  (to  the  extent  of 
700  volumes)  in  water,  forming  a  strong 
solution  designated  as  ammonium  hy- 
droxide (sp.  gr.,  0.807  at  25°  C,  U.  S. 
P.). 

PREPARATIONS  AND  DOSE.— 
The  preparations  of  ammonia  included 
in  the  U.  S.  Pharmacopoeia  are  as  fol- 
lows : — 

Aqua  ammonicc  (ammonia  water, 
hartshorn),  containing  10  per  cent,  by 
weight  of  ammonia  gas;  dose,  10  to  30 
minims  (0.6  to  2.0  c.c). 

Aqua  ammonia:  fortior  (stronger  am- 
monia water),  containing  28  per  cent, 
by  weight  of  ammonia  gas ;  used  chiefly 
externally  as  a  vesicant. 

Spiritus  ammonicc  (spirit  of  ammo- 
nia), an  alcoholic  solution,  containing 
10  per  cent,  of  ammonia ;  dose,  10  to  30 
minims  (0.6  to  2.0  c.c). 

Spiritus  ammoiiirc  aromaticus  (aro- 
matic spirit  of  ammonia),  composed  of 
ammonium  carbonate,  34  parts  by 
v/eight;  ammonia  water,  90  parts  by 
volume;  oil  of  lemon,  10  parts;  oils  of 
lavender  flowers  and  of  nutmeg,  of  each, 
1  part ;  alcohol,  700  parts  ;  water,  enough 
to  make  1000  parts.  A  nearly  colorless 
liquid  when  fresh,  but  gradually  becom- 
ing darker;  dose,  30  to  60  minims  (2.0 
to  4.0  c.c). 

Linimciiturn  ammonice  (ammonia  lini- 
ment), composed  of  ammonia  water, 
350  parts  by  volume  ;  alcohol,  50  parts  ; 
cottonseed  oil,  570  parts ;  oleic  acid,  30 
parts.  Should  be  freshly  prepared  when 
wanted. 

The  following  non-official  prepara- 
tions have  also  occasionally  been  used : — 

Fetid  spirit  of  ammonia,  composed 
of  asafetida,  1  part;  spirit  of  ammonia, 
21  parts;  dose,  30  minims  (2.0  c.c). 

Camphorated  ammonia  liniment,  com- 
posed of  ammonia  water,  30  parts ;  cam- 
phor liniment,  70  parts. 


Ointment  of  ammonia,  composed  of 
ammonia  water,  17 parts;  lard, 32 parts; 
oil  of  sweet  almonds,  2  parts. 

MODES  OF  ADMINISTRA- 
TION.—Ammonia  is'  miscible  in  all 
proportions  with  water  and  alcohol. 
The  most  agreeable  preparation  for  in- 
ternal use  is  the  aromatic  spirit,  which 
should  always  be  given  well  diluted  with 
water.  As  a  stimulating  inhalation,  the 
gas  arising  from  ammonium  carbonate 
(the  ordinary  "smelling  salts")  is  fre- 
quently employed;  but  this  may  readily 
be  replaced  by  the  simple  ammonia  wa- 
ter, or,  if  additional  care  is  used,  by  the 
stronger  ammonia  water.  The  spirit 
and  the  water  of  ammonia  have  also 
been  administered  hypodermically,  or 
even  intravenously,  as  stimulants,  though 
their  action  is  but  fleeting,  and  consid- 
erable local  irritation  may  arise.  In 
pneumonia  and  other  dyspneic  states  a 
little  ammonia  water  dropped  into  boil- 
ing water"  at  frequent  intervals  will 
"soften"  the  atmosphere  and  greatly 
facilitate  breathing. 

Externally,  the  stronger  ammonia 
water  may  be  applied  in  full  strength 
as  a  vesicant,  and  the  area  under 
treatment  should  be  covered  with  a 
watch-glass  to  prevent  evaporation. 
For  counterirritant  efTfects,a  10  percent, 
aqueous  preparation,  such  as  the  weaker 
ammonia  water,  or  a  stronger  oily  prep- 
aration, such  as  the  official  ammonia 
liniment,  is  suitable.  In  children  with 
delicate  skins  these  preparations  should 
be  further  diluted.  In  spasmodic  croup 
a  little  ammonia  added  to  water  and  ap- 
plied to  the  child's  neck  and  chest  by 
means  of  a  cloth  will  often  bring  con- 
siderable relief,  though  much  care  is  re- 
quired to  have  the  fluid  sufficiently  di- 
lute and  not  to  leave  it  on  too  long.  The 
evanescence  of  the  effects  of  ammonia 
resulting  from    its    volatility    requires 


608 


AMMONIA    (SAJOUS). 


that  its  administration  be  frequently  re- 
peated. 

INCOMPATIBLES.— Mineral  or 

vegetable  acids  and  acid  salts,  which 
ammonia  neutralizes  with  the  formation 
of  neutral  salts;  salts  of  the  alkaloids, 
which  ammonia  may  cause  to  be  precip- 
itated by  combining  with  the  acid  radi- 
cal (thereby  setting  free  the  more  or 
less  insoluble  pure  alkaloid)  ;  chlorine, 
bromine,  and  iodine,  with  which  ammo- 
nia combines  to  form  corresponding 
salts ;  mercurial  and  most  other  metallic 
salts,  with  which  ammonia  forms  in- 
soluble mixed  salts  or  hydroxides. 

CONTRAINDICATIONS.— In 
acute  inflammations  of  the  stomach  and 
in  cases  where  the  urine  is  abnormally 
acid  the  internal  use  of  ammonia  is  to 
be  avoided.  In  small  children  and  in 
persons  with  a  sensitive  respiratory 
tract,  the  inhalation  of  ammonia  fumes 
is  likewise  apt  to  be  prejudicial,  large 
amounts  giving  rise  to  a  bronchitis. 

PHYSIOLOGICAL  ACTION.— 
Local  Effects. — Solutions  of  ammonia 
strongly  irritate  any  tissues  with  which 
they  may  be  brought  in  contact.  Ap- 
plied to  the  skin,  they  act  as  rubefa- 
cients or  vesicants,  according  to  the  con- 
centration of  the  preparation  used  and 
the  length  of  time  it  is  left  on  the  tis- 
sues. On  the  mucous  membranes,  es- 
pecially the  conjunctivae,  the  buccal  and 
the  respiratory  mucosae,  ammonia  vapor 
acts  primarily  as  a  stimulant,  exciting 
the  local  nerve-terminals,  causing  in- 
creased flow  of  glandular  secretions, 
and,  when  concentrated,  spasm  of  the 
glottis;  when  kept  in  contact  for  a 
longer  time,  ammonia  preparations 
cause  inflammatory  changes  which  may 
result  in  local  death  of  the  tissues,  fol- 
lowed by  sloughing.  The  caustic  action 
of  ammonia  is  due,  as  is  the  case  with 
oth/^r  alkali^  <ki>  .a  c/^^kinati&a  w'^h  the 


tissue  albumins,  resulting  in  the  forma- 
tion of  alkali  albuminates,  and  with  the 
fats  to  form  soaps.  The  great  penetrat- 
ing power  of  ammonia,  due  to  its  vola- 
tility, renders  it,  when  concentrated, 
one  of  the  most  deeply  acting  of  corros- 
ives. 

Effects  on  Internal  Use. — Nervous 
System. — After  being  absorbed  into  the 
circulation,  ammonia  stimulates,  for  a 
short  period,  the  medulla  oblongata  and 
the  motor  side  of  the  spinal  cord.  The 
higher  brain-centers  are,  if  anything, 
shghtly  depressed.  The  spinal  stimula- 
tion results  in  an  exaggeration  of  re- 
flex activity  and,  with  excessive  doses, 
in  convulsions.  Succeeding  the  stage  of 
stimulation,  a  secondary  stage  of  de- 
pression of  the  medullary  centers  and 
spinal  cord  may  occur  with  large  doses. 

Circulation. — Ammonia  stimulates  the 
heart  muscle,  the  vasomotor  center  in 
the  medulla,  and,  to  a  less  extent,  the 
inhibitory  (vagus)  center,  likewise  in 
the  medulla.  These  effects  result  mainly 
in  a  pronounced  rise  of  the  general 
blood-pressure.  The  heart  beats  more 
strongly,  but  its  rate  is  frequently 
slowed.  Excessive  doses  may  lead  to  a 
secondary  depression  of  both  the  heart 
and  vasomotor  mechanism. 

Respiration. — The  respiratory  centers 
in  the  medulla  are  strongly  stimulated 
by  ammonia.  Both  rate  and  depth  of 
breathing  are  increased  through  its  ac- 
tion. 

Secretions. — ^Ammonia  and  the  am- 
monium compounds  stimulate  the  flow 
of  body  secretions,  especially  the  sweat, 
saliva,  and  mucous  secretions.  The  dia- 
phoretic effect  is  believed  to  be  wholly 
central,  i.e.,  due  exclusively  to  excita- 
tion of  the  sweat-center  in  the  medulla. 
The  other  secretory  effects  are  ascribed 
both  to  a  central  action  and  to  a  local 
^£ect  on  the  gland-cells. 


AMMONIA    (SAJOUS). 


609 


Digestive  Tract. — Moderate  doses  of 
ammonia  stimulate,  like  other  alkalies, 
the  gastric  glands  if  taken  before  meals. 
After  meals  they  neutralize  the  acids 
of  the  gastric  juice.  Large  amounts  of 
ammonia  exert  a  corrosive  action  on  the 
mucosae  (r.  Ammonia  Poisoning). 

Absorption  and  Elimination. — Con- 
cerning the  manner  in  which  ammonia 
exerts  its  stimulating  effect,  there  are 
still  differences  of  opinion.  Some  claim 
that,  after  being  rapidly  absorbed,  am- 
monia, circulating  with  the  blood,  stim- 
ulates the  vital  centers  directly;  others 
believe  that  the  centers  are  stimulated 
mainly  reflexly,  as  a  result  of  the  local 
irritation  produced  in  the  stomach. 

The  researches  of  Magnus  showed 
ammonia  to  be  neither  absorbed  nor  ex- 
creted by  the  lungs.  Hence,  in  so  far  as 
its  administration  by  inhalation  is  con- 
cerned, the  stimulating  effects  of  am- 
monia would  appear  to  be  due  largely 
to  peripheral  sensory  stimulation. 

When  taken  internally^  on  the  other 
hand,  ammonia  is  readily  absorbed;  but 
on  reaching  the  blood-stream  it  rapidly 
undergoes  a  chemical  change  whereby 
it  is  converted  into  the  relatively  inert 
substance  urea.  Whatever  direct  stim- 
ulating action  it  may  exert  on  the  nerve- 
centers  and  heart  is,  therefore,  quickly 
brought  to  an  end. 

By  the  conversion  into  urea,  the  am- 
monium in  ammonium  hydroxide  loses 
the  characteristics  of  an  alkali  metal. 
For  this  reason  ammonia  does  not  in- 
crease the  alkalinity  of  the  body  fluids, 
differing  thus  from  the  hydroxides  of 
sodium  and  potassium,  which  cannot 
undergo  the  change  referred  to. 

The  urea  produced  from  the  ammo- 
nia is  naturally  eliminated  largely  with 
the  urine,  which  may  be  somewhat  in- 
creased in  amount  owing  to  stimulation 
of  the  renal  cells  by  the  excess  of  urea. 


TOXICOLOGY.— The  ingestion  of 
strong  solutions  of  ammonia  results  in 
corrosion  or  violent  inflammation  of 
the  mucous  membranes  of  the  mouth, 
esophagus,  and  stomach,  and  in  marked 
irritation  of  the  larynx  and  trachea, 
owing  to  the  penetration  of  ammonia 
vapor  into  the  respiratory  passages. 
The  symptoms  consist  of  violent  pain 
in  the  mouth,  throat,  and  abdomen ;  sali- 
vation ;  vomiting,  sometimes  bloody, 
and,  occasionally,  purging.  The  intense 
irritation  of  the  respiratory  mucous 
membranes  may  cause,  at  first,  a  mo- 
mentary arrest  of  breathing  and  de- 
pressed heart  action,  as  well  as  spas- 
modic contraction  of  the  laryngeal  and 
bronchial  muscles.  Later,  the  persist- 
ing laryngeal  irritation  causes  intense 
local  burning  and  a  characteristic  diffi- 
culty of  respiration,  due  to  actual  edem- 
atous swelling  of  the  glottis.  Sudden 
death  by  asphyxia  may  result,  though 
more  frequently  it  is  due  to  shock  aris- 
ing from  the  pronounced  local  destruct- 
ive effects  of  the  alkali,  or  to  collapse, 
possibly  owing  to  a  secondary  depress- 
ive effect  of  the  drug  on  the  heart  and 
medullary  centers.  Convulsions,  how- 
ever, are  comparatively  infrequent  in 
ammonia  poisoning,  and  this  fact  would 
tend  to  indicate  that  in  the  majority  of 
cases  the  amount  of  ammonia  absorbed 
is  insufficient  to  cause  violent  direct  ef- 
fects on  the  nerve-centers. 

The  ultimate  results  in  cases  of  am- 
monia poisoning  can  seldom  be  pre- 
dicted with  certainty.  Not  only  may 
laryngeal  or  bronchial  inflammation  fol- 
low, but  the  gastric  mucosa  may  be  so 
greatly  injured  as  permanently  to  im- 
pair the  functions  of  the  stomach,  and 
even  cause  death  from  inanition.  More- 
over, in  cases  that  recover  from  the 
acute  effects,  stricture  of  the  esophagus 
is  a  frequent  sequela.     As  with  other 


1—39 


610 


AMMONIA    (SAJOUS). 


caustics,  the  upper  and  lower  extremi- 
ties of  the  gullet  and  the  point  at  which 
it  crosses  the  left  bronchus  are  the  fa- 
vorite seats  of  corrosion. 

Large  doses  of  ammonia  (providing 
a  sufficient  amount  is  absorbed)  are  said 
to  diminish  the  oxygen-absorbing  power 
of  the  red  blood-corpuscles  and  to  inter- 
fere with  coagulation. 

Treatment  of  Ammonia  Poisoning. 
— The  chief  ends  to  be  sought  in  the 
treatment  of  the  first  stage  of  the  poison- 
ing are  neutralization,  dilution,  and  re- 
moval of  the  obnoxious  agent.  Vine- 
gar, lemon  juice,  or  any  other  avail- 
able acid  (preferably  a  vegetable 
acid),  well  diluted,  should  be  given, 
together  with  a  large  amount  of 
water.  Where  no  acid  is  at  hand,  an 
oil,  such  as  olive  oil  or  linseed  oil, 
forms  the  best  substitute.  The  stom- 
ach-pump may  then  be  cautiously 
used,  though,  if  sufficient  time  for 
marked  corrosion  of  the  tissues  has  al- 
ready elapsed,  its  passage  is  attended 
with  some  danger,  owing  to  the  liability 
of  the  weakened  tissues  to  perforation. 

Morphine  should  be  given  if  the 
pain  is  severe,  and  tracheotomy  may 
be  required  if  asphyxia  threatens. 

If  symptoms  of  shock  or  secondary 
collapse  appear,  the  usual  measures  for 
combating  these  states  —  hypodermic 
injections  of  ether,  digitalis,  atropine, 
strychnine;  hot,  strong  coffee  by  the 
rectum ;  external  heat,  artificial  respi- 
ration, etc. —  should  be  availed  of. 

Demulcents,  such  as  olive  oil,  starch 
paste,  tragacanth  mucilage,  milk, 
white  of  egg,  or  an  infusion  of  elm 
bark,  should  be  freely  administered 
to  soothe  the  inflamed  mucous  mem- 
branes. No  food  is  to  be  given  by 
the  mouth  for  twoi  days  after  the 
accident. 

Strictures  of   the   esophagus   should 


be  treated  by  dilatation  with  bougies 

{v.  Esophagus,  Stricture  of). 
APPLIED  THERAPEUTICS  OF 

AMMONIA.— As  a  Stimulant.— Am- 
monia is  of  great  value  as  a  rapidly 
acting  "diffusible"  stimulant,  exerting 
a  marked  beneficial  effect  in  all  forms 
of  acute  circulatory,  respiratory,  and 
nervous  depression.  It  may  be  admin- 
istered either  by  the  mouth,  by  inhala- 
tion, or  by  hypodermic  or  intravenous 
injection.  For  internal  use,  the  aro- 
matic spirit  of  ammonia,  always  well 
diluted,  in  doses  of  15  minims  to  1 
dram  (1  to  4  c.c),  is  the  best  prep- 
aration. For  inhalation,  ordinary  am- 
monia water,  or  "smelling  salts,"  may 
be  used.  The  effect  of  ammonia,  when 
it  is  taken  internally,  is  believed  by 
some  to  be  chiefly  reflex,  varying  in 
intensity  with  the  degree  of  local  irrita- 
tion produced.  A  similar  mode  of  ac- 
tion is  known  to  obtain  when  ammonia 
is  inhaled;  none  of  it  is  absorbed 
through  the  lungs,  and  the  effect  is  cor- 
respondingly fugacious.  The  true  stim- 
ulating effect  of  ammonia  is  best  ob- 
tained by  intravenous  injection,  though 
the  hypodermic  method  is  oftener  em- 
ployed. 

In  asphyxia,  whatever  be  its  origin, 
ammonia  is  a  valuable  agent.  It  may, 
wath  advantage,  be  given  at  once  inter- 
nally and  by  inhalation.  During  the 
latter  procedure  care  should  be  taken 
not  to  spill  any  of  the  strong  liquid  into 
the  patient's  mouth  or  nose, — an  acci- 
dent which  is  likely  to  occur  when  the 
patient  is  recumbent,  and  which  is  apt 
to  yield  a  more  pronounced  effect,  how- 
ever, than  its  ingestion. 

In  cases  of  sudden  heart-failure  or 
collapse,  as  may  result  from  the  pres- 
ence of  bacterial  toxins  or  poisoning 
by  depressant  drugs,  such  as  hydro- 
cyanic  acid,   chloroformj   chloral  hy- 


AMMONIA    (SAJOUS). 


611 


drate,  aconite,  etc.,  repeated  ingestion 
of  15  minims  to  1  dram  of  the  aro- 
matic spirit  of  ammonia,  diluted  with 
half  a  tumblerful  of  water,  or  the  in- 
travenous injection  of  like  amounts  of 
ammonia  water,  diluted  with  6  drams 
of  sterile  water,  will  usually  exert  a 
powerful  stimulating  action.  Ammo- 
nia may  likewise  be  used  internally  to 
combat  the  effects  of  bites  of  poison- 
ous animals. 

In  ordinary  "fainting"  and  the 
lighter  forms  of  shock,  the  inhalation 
of  ammonia  from  its  solution  or  from 
smelling  salts  may  suffice  to  bring  about 
the  desired  result. 

In  infants,  collapse  occurring  in 
summer  diarrhea  may  be  combated  with 
occasional  doses  of  a  few  drops  of  am- 
monia, well  diluted. 

For  the  algid  stage  of  cholera,  am- 
monia internally  and  ether  hypoder- 
mically,  with  simultaneous  free  admin- 
istration of  alcohol,  have  been  highly 
recommended  by  Giacich.  Marked  im- 
provement in  the  general  condition  was 
noted  within  two  hours  after  the  insti- 
tution of  this  mode  of  treatment,  and 
over  50  per  cent,  of  cases  already  in 
the  algid  stage  are  said  to  have  recov- 
ered. 

In  acute  alcoholic  intoxication,  the 
ammonia  preparations  are  consider- 
ably used.  Lavage  of  the  stomach, 
followed  b}^  the  administration  of  10 
drops  of  ammonia  water  in  a  half-tum- 
blerful of  water,  will  often  counteract 
promptly  the  effects  of  the  alcohol. 
Ammonia  has  also  been  used  with 
benefit  in  the  treatment  of  delirium 
tremens  (Butler). 

As  an  Antacid. — Internally,  am- 
monia may  be  used  to  counteract 
gastric  hyperacidity,  indicated  by 
such  symptoms  as  acid  eructations 
("heartburn")     and    flatulence.       Par- 


ticularly where  there  are  pronounced 
abnormal  fermentative  processes,  re- 
sulting in  the  formation  of  vegetable 
acids,  does  ammonia  appear  to  be  effi- 
cient. A  few  drops  (3  to  5)  of  the 
water  of  ammonia,  or  10  drops  of  the 
aromatic  spirit,  well  diluted, will  often 
give  relief  under  these  circumstances. 
It  should  be  remembered  that,  al- 
though the  ammonia  introduced  will 
tend  to  neutralize  any  acids  present, 
the  local  irritation  produced  by  it  will, 
in  addition,  tend  to  stimulate  the  gas- 
tric glands  and  musculature.  Hence 
the  special  degree  of  benefit  obtained 
where  there  is  flatulence  and  in  cases 
where  the  gastric  functions  are  weak- 
ened by  general  debility  or  excessive 
alcoholic  indulgence. 

In  poisoning  by  mineral  acids,  such 
as  hydrochloric  or  sulphuric  acids,  well- 
diluted  ammonia  may  be  given  as  an 
antidote  (though  a  less-irritating  alkali, 
when  at  hand,  is  much  preferable). 

Externally,  in  painful  insect  bites, 
ammonia  may  be  used  to  neutralize  the 
acid  (frequently  formic  acid)  intro- 
duced at  the  moment  of  stinging.  Its; 
antiseptic  action  is  also  helpful. 

As  a  Counterirritant,  Rubefacient, 
or  Cauterant. — Ammonia  water  ap- 
plied to  the  skin  acts  powerfully  in  re- 
lieving subjacent  pain,  though  the  su- 
perficial pain  attending  its  use  is  not 
infrequently  more  severe  than  is  the 
case  with  other  counterirritants. 

In  patients  with  kidney  affections,  in 
particular,  it  has  been  used  as  a  vesi- 
cant in  place  of  cantharides,  which 
causes  harmful  renal  irritation  in  these 
cases.  It  has  the  property  of  passing 
through  the  horny  layer  of  the  epider- 
mis without  destroying  it  (as  would 
other  strong  alkalies),  and  of  inducing 
blister  formation  through  irritation  ol 
the  dermis. 


612 


AMMONIUM    (SAJOUS). 


In  bruises,  chilblains,  and  other  su- 
perficial lesions,  ammonia  liniment 
may  be  employed  as  a  rubefacient.  It 
sometimes  relieves  the  milder  forms 
of  chronic  rheumatism,  including  the 
joint  manifestations  and  lumbago. 

The  corrosive  and  antiseptic  prop- 
erties of  ammonia  may  be  utilized 
Avith  great  advantage  and  convenience 
in  treating  the  bites  of  carnivorous 
animals,  venomous  reptiles  and  in- 
sects. In  snake-bites,  for  example, 
strong  ammonia  w^ater  may  be  applied 
directly  to  the  wound,  the  general  stim- 
ulating effect  of  ammonia  being  also 
availed  of  by  giving  an  intravenous  in- 
jection of  30  to  60  minims  of  the 
weaker  solution  in  6  drams  of  sterile 
water.  In  insect  stings,  the  local  appli- 
cation of  ammonia  water  will  often 
greatly  reduce  the  pain  or  itching;  es- 
pecially where  a  tendency  to  local  in- 
fection exists,  the  antiseptic  property 
of  the  remedy  may  be  utilized  with 
great  benefit.  The  patient  should  al- 
ways be  cautioned,  however,  to  remove 
the  ammonia  when  marked  redness  of 
the  skin  appears ;  otherwise,  consider- 
able local  injury  is  likely  to  result.  In 
a  case  witnessed  by  the  writers,  the  pa- 
tient had  used  it  in  the  form  of  a  com- 
press to  treat  a  horse-fly  bite.  The  large 
area  thus  "treated"  resembled  a  burn  of 
the  second  degree.  Most  people  handle 
ammonia  carelessly. 

In  the  "hair  tonics"  recommended 
in  premature  alopecia,  ammonia  wa- 
ter is  considered  a  valuable  ingre- 
dient. The  aromatic  spirit  of  am- 
monia is  also  used  in  various  other 
affections  of  the  scalp,  including 
pityriasis,  etc. 

C.  E.  DE  M.  Sajous 

AND 

L.  T.  DE  M.  Sajous, 

Philadelphia. 


AMMONIUM.— A  metal-like  body, 
never  yet  isolated  in  pure  form,  but 
known,  from  the  manner  in  which  its 
compounds  can  be  formed  by  the  in- 
teraction of  ammonia  gas  and  acids,  to 
have  the  chemical  composition  NH4. 
The  compounds  of  ammonium  greatly 
resemble  those  of  potassium;  hence  the 
inclusion  of  ammonium  in  the  group  of 
alkali  metals.  The  official  salts  of  am- 
monium are  the  following: — 

Ammo'iiii  hensoas  (ammonium  ben- 
zoate)  ;  dose,  5  to  30  grains  (0.3  to  2.0 
grams). 

Ammonii  hromiduni  (ammonium  bro- 
mide) ;  dose,  5  to  30  grains  (0.3  to  2.0 
grams). 

Ammonii  carbonas  (ammonium  car- 
bonate) ;  dose,  2  to  15  grains  (0.12  to 
1.0  gram). 

Ammonii  chloridum  (ammonium 
chloride)  ;  dose,  2  to  30  grains  (0.12 
to  2.0  grams). 

Ammonii  iodidum  (ammonium  io- 
dide) ;  dose,  3  to  15  grains  (0.2  to  1.0 
gram). 

Ammonii  salicylas  (ammonium  sali- 
cylate) ;  dose,  3  to  15  grains  (0.2  to 
1.0  gram). 

Ammonii  valeras  (ammonium  vale- 
rianate or  valerate)  ;  dose,  2  tO'  10 
grains  (0.12  to  0.6  gram). 

Ammonium  acetate  is  ofificial  in 
liquor  ammonii  acetatis  (spirit  of  Min-  , 
dererus),  a  solution  of  diluted  acetic 
acid  nearly  saturated  with  ammo- 
nium carbonate;  dose,  4  fluidrams 
(16  c.c,  containing  about  15  grains 
or  1  gram  of  ammonium  acetate), 
and  in  liquor  ferri  et  ammonii  acetatis 
(Basham's  mixture),  which  is  made 
up  of  tincture  of  ferric  chloride,  1 
fluidram  (4  c.c.)  ;  diluted  acetic  acid, 
1%  fluidrams  (6  c.c.)  ;  solution  of 
ammonium  acetate,  12^^  fluidrams 
(50  c.c.)  ;  aromatic  elixir,  3  fluidrams 


AMMONIUM    (SAJOUS). 


613 


(12  c.c.)  ;  glycerin,  3  fluidrams  (12 
c.c),  and  water,  enough  to  make  25 
fluidrams  (100  c.c.)  ;  dose,  4  fluidrams 
(16  c.c). 

PHYSIOLOGICAL  ACTION.— 
The  efl:"ects  of  the  compounds  of  am- 
monium are  a  composite  of  those  of  the 
ammonium  group  or  ion  itself,  and  of 
the  acid  group  in  union  with  it.  The 
latter  may  not  only  modify  that  of  the 
ammonium,  as  in  ammonium  bro- 
mide, but  may  completely  overshadow 
it,  as  in  ammonium  arsenate. 

The  effects  of  the  ammonium  ion, 
when  it  enters  the  circulation,  are,  in 
general,  those  of  a  promptly  acting,  but 
fleeting  stimulant.  If  the  amount  in- 
troduced be  excessive,  depression  may 
follow  the  primary  stimulation. 

In  the  nervous  system  the  stimulat- 
ing effects  of  ammonium  bear  chiefly 
upon  the  spinal  cord  and  medulla.  The 
motor  spinal  centers  are  excited  to  in- 
creased activity,  exaggerated  reflex  ac- 
tion, and  even  convulsions,  being  among 
the  most  evident  results.  The  cere- 
brum, however,  is,  if  anything,  de- 
pressed rather  than  stimulated.  The 
circulation  is  influenced  in  various 
ways :  1.  Stimulation  of  the  vaso- 
motor center  in  the  medulla  causes 
a  rise  of  blood-pressure  through 
constriction  of  the  peripheral  blood- 
vessels. 2.  The  heart  muscle  is 
directly  stimulated,  the  result  being 
a  strengthening  of  its  beats  and 
further  rise  in  the  blood-pressure.  3. 
Excitation  of  the  vagus  (inhibitory) 
center  in  the  medulla  may  cause  some 
slowing  in  the  heart  rate.  Respiration 
is  accelerated  and  deepened  through 
stimulation  of  the  medullary  centers 
presiding  over  this  function.  The  body 
secretions,  especially  the  sweat,  saliva, 
and  mucous  secretions  of  the  alimen- 
tary   and    respiratory    tracts,    are    in- 


creased by  ammonium,  partly  through 
stimulation  of  the  nervous  centers  gov- 
erning secretory  processes  (exclusively 
so  in  case  of  the  sweat  secretion),  and 
partly  owing  to  local  effects  on  the  se- 
creting cells. 

Though  most  of  the  ammonium  com- 
pounds are  readily  and  promptly  ab- 
sorbed from  the  stomach  and  intestines, 
their  excretion  through  the  urine  and 
other  secreted  fluids  is  so  rapid  as  to 
greatly  limit  the  power  and  duration  of 
their  effects  when  taken  by  the  mouth. 
Further,  certain  of  the  salts  of  ammo- 
nium, i.e.,  the  acetate  and  citrate,  when 
absorbed,  are  oxidized  to  ammonium 
carbonate  in  the  system,  and  this,  in 
turn,  undergoes  a  rapid  decomposition, 
probably  mainly  in  the  liver,  whereby 
it  is  converted  into  urea.  The  ammo- 
nium group  is  thus  destroyed,  and  its 
specific  effects  promptly  disappear. 
Only  by  intravenous  injection  of  rather 
considerable  amounts  Of  ammonium 
salts  are  the  effects  of  the  NH4  group 
obtained  with  any  degree  of  intensity. 

The  decomposition  of  the  NH4  group 
into  urea  involves  loss  of  the  alkaline 
properties  of  its  compounds.  For  this 
reason  the  alkalinity  of  the  blood  is  not 
increased  and  the  acidity  of  the  urine 
not  diminished  by  the  administration  of 
alkaline  salts  of  ammonium,  as  they 
would  be  by  giving  alkaline  salts  of  so- 
dium and  potassium. 

Ammonium  salts  which  are  not 
changed  to  the  carbonate  and  elimi- 
nated as  urea — e.g.,  ammonium  chlo- 
ride— are  excreted  as  neutral  salts,  and, 
therefore,  also  fail  to  influence  the  re- 
action of  the  urine. 

The  contrast  between  the  stimulating 
action  of  ammonium  hydroxide  (am- 
monia) or  ammonium  carbonate  and 
the  almost  complete  absence  of  it  in  the 
case  of  amrnonium  chloride  is  now  b^- 


614 


AMMONIUM    (SAJOUS). 


lieved  to  be  due  not  to  any  greater  ra- 
pidity of  absorption  or  more  prolonged 
persistence  of  ammonium  in  the  blood 
(the  reverse  being,  in  reality,  the  case), 
but  to  the  reflex  stimulation  caused  by 
the  caustic  alkaline  action  of  the  first- 
mentioned  two  compounds  on  the  gas- 
tric mucosa  (or  wherever  else  brought 
into  relation  with  the  organism),  as 
compared  to  the  low  degree  of  local  ir- 
ritation caused  by  the  practically  neu- 
tral chloride  of  ammonium. 

As  already  mentioned,  some  of  the 
ammonium  compounds  owe  their 
therapeutic  value  chiefly  to  the  acid 
group — benzoate,  bromide,  salicylate, 
etc. — with  which  the  ammonium  is  in 
combination.  For  information  con- 
cerning these  the  reader  is  referred  to 
the  headings  under  which  the  respect- 
ive acids  are  considered :  Benzoic 
acid,  bromides,  salicylic  acid,  etc.  The 
more  important  of  the  compounds  in 
the  physiological  action  of  which  the 
ammonium  group  plays  the  leading 
part  will  be  treated  of  in  the  following 
sections. 

AMMONIUM  ACETATE.— Am- 
monium acetate  (CH3.  COONH4)  oc- 
curs as  a  white  crystalline  solid,  freely 
soluble  in  water.  It  is  seldom  used  in 
its  natural  state,  but  enters  into  the 
composition  of  the  official  liquor  am- 
monii  acetatis  (spirit  of  mindererus), 
which  is  extensively  employed.  This 
fluid  is  prepared  by  neutralizing  dilute 
acetic  acid  with  ammonium  carbonate 
(5  grams  of  the  former  in  100  c.c.  of 
the  latter,  according  to  pharmacopeia! 
directions),  the  result  being  a  colorless 
Hquid,  which  may  give  off  a  faint  odor 
of  acetic  acid,  and  has  a  mildly  saline, 
acidulous  taste  and  an  acid  reaction. 
The  preparation  is  required  to  contain 
not  less  than  7  per  cent,  of  ammonium 
acetate,  and  should  be  freshly  prepared 


when  wanted.  The  dose  of  spirit  of 
mindererus  is  2  fluidrams  to  1  ounce 
(8.0  to  30.0  c.c),  repeated  every  two  or 
three  hours. 

Liquor  fcrri  et  ammonii  acetatis 
(Basham's  mixture)  will  be  considered 
among  the  preparations  of  iron. 

MODE  OF  ADMINISTRATION. 
— Liquor  ammonii  acetatis  is  best  ad- 
ministered well  diluted  in  sweetened 
water.  Sparkling  water  (charged  with 
carbon  dioxide)  is  also  advantageous  as 
a  diluent. 

INCO  MP  ATIBLES.  — Strong 
acids,  which  enter  in  combination  with 
the  ammonium,  replacing  the  weaker 
acetate  radical;  compounds  of  bases 
stronger  than  ammonium  (sodium,  po- 
tassium), with  acids  weaker  than  acetic 
acid,  e.g.,  the  carbonates  of  sodium  and 
potassium;  lime  water  (calcium  hy- 
droxide) ;  metallic  salts,  such  as 
those  of  silver  and  lead. 

PHYSIOLOGICAL  ACTION.— 
Ammonium  acetate,  especially  when 
given  in  the  official  solution,  is  the  most 
strongly  diaphoretic  of  the  salts  of  am- 
monium. Its  action  is  believed  to  take 
place  largely,  if  not  solely,  through 
stimulation  of  the  sweat-center.  The 
diaphoresis  occurring  under  its  influ- 
ence is  greatly  assisted  if  the  cutaneous 
vessels  are  already  in  a  state  of  dilata- 
tion or  are  caused  to  dilate  by  the  ap- 
plication of  warmth — blankets — to  the 
patient's  skin,  or  by  combination  with 
sweet  spirit  of  niter  or  aconite. 

A  second  useful  property  of  this  salt 
is  its  action  as  a  diuretic.  This  ac- 
tion is  exerted  most  strongly  when 
diaphoresis  is  held  in  abeyance,  i.e., 
when  the  skin  vessels  are  not  dilated. 
The  diuretic  effect  of  ammonium  ace- 
tate is  not  produced  through  irritation 
of  the  kidney-cells.  This  is  one  of  the 
ammonium  salts  which  are  rapidly  con- 


AMMONIUM    (SAJOUS). 


615 


verted  in  the  system,  first  into  ammo- 
nium carbonate,  then  into  urea;  hence 
the  diuretic  effect  is  probably  chiefly 
that  of  urea, — a  normal  stimulant  to  the 
renal  function. 

Ammonium  acetate  is  believed  to  be 
one  of  the  most  rapidly  absorbed  of  the 
ammonium  salts ;  we  should,  therefore, 
expect  that  some  of  the  stimulating  ac- 
tion of  ammonium  on  the  medullary 
nerve-centers  and  circulation  would  be 
exerted  on  ingestion  of  this  salt.  Such 
stimulation  does  not,  however,  with  the 
exception  of  the  sweat-center,  appear 
to  occur  to  any  marked  extent.  The 
reason  for  the  special  preponderance  of 
diaphoresis  in  the  action  of  this  salt  of 
ammonium  is  not  definitely  known. 

THERAPEUTICS.— As  a  Diapho- 
retic and  Diuretic. — The  solution  of 
ammonium  acetate  is  useful  as  a  mild 
sweat-producer  and  diuretic  in  febrile 
diseases,  including  acute  coryza,  in- 
fluenza, mumps,  the  eruptive  diseases 
of  childhood,  etc.  The  elimination  of 
toxic  products,  in  which  the  skin,  as 
well  as  the  kidneys,  plays  so  important 
a  part  in  these  affections,  is  hastened 
by  it.  It  also  tends  to  reduce  excess- 
ive temperatures  by  increasing  the 
amount  of  fluid  evaporated  from  the 
skin.  In  the  diseases  of  childhood, 
when  the  eruption  is  delayed,  am- 
monium acetate  will  favor  its  ap- 
pearance. It  has  also  been  found 
serviceable  in  muscular  rheumatism 
(Butler). 

In  acute  alcoholic  intoxication  am- 
monium acetate  has  been  found  to  re- 
move promptly  the  symptoms.  In 
migraine,  too,  through  some  obscure 
mode  of  action,  and  in  amenorrhea, 
the  remedy  has  sometimes  proved 
beneficial  (Butler). 

Externally,  solutions  of  ammonium 
acetate  have  been  applied  as  a  lotion 


over  contusions,  beginning  abscesses 
and  glandular  enlargements,  and  cer- 
tain skin  diseases,  e.g.,  prurigo.  In 
chronic     ophthalmic     inflammations, 

also,  it  has  been  used  as  an  eye-wash, 
a  little  laudanum  being  added  to  the 
acetate  solution  in  order  to  relieve 
local  discomfort. 

AMMONIUM  CARBONATE.— 
The  substance  used  under  this  name  is 
not  the  pure  carbonate  of  ammonium, 
(NH4)2C03,  but  is  a  mixture  in  va- 
riable ratio  of  acid  ammonium  bicar- 
bonate, (NH4)HC03  or  CO(OH)- 
ONH4,  and  ammonium  carbamate,  CO- 
(NH2)ONH4.  This  mixture  is  also 
known  as  ammonium  sesquicarbonate, 
hartshorn,  sal  volatile,  Preston  salts,  or 
bakers'  ammonia.  It  is  made  by  heat- 
ing an  ammonium  salt,  such  as  the  chlo- 
ride, with  chalk  (calcium  carbonate), 
and  occurs  in  white,  hard,  translucent 
masses  having  a  sharp,  saline  taste,  a 
strong  odor  of  ammonia,  and  a  strongly 
alkaline  reaction  to  litmus.  It  loses 
both  ammonia  gas  and  carbon  dioxide 
when  exposed  to  the  air,  and  effloresces, 
becoming  opaque  and  friable.  When 
heated  it  volatilizes  completely.  When 
dissolved  in  hot  water  it  is  decomposed, 
ammonia  and  carbon  dioxide  being 
driven  off;  upon  further  boiling  it  dis- 
appears from  the  solution  by  volatiliza- 
tion. It  is  soluble  in  5  parts  of  water 
at  a  temperature  of  15°  C.  (59°  F.), 
and  in  4  parts  at  25°  C.  {77°  F.).  Al- 
cohol dissolves  only  its  carbamate  con- 
stituent, the  acid  carbonate  remaining. 
In  glycerin  it  is  soluble  to  the  extent  of 
1  in  5  parts.  The  purity  standard  set 
for  ammonium  carbonate  by  the  United 
States  Pharmacopoeia  is  that  it  should 
contain  97  per  cent,  of  the  constituents 
above  mentioned,  and  should  yield  not 
less  than  31.58  per  cent,  of  ammonia 
gas. 


616 


AMMONIUM    (SAJOUS). 


The  dose  of  ammonil  carbonas  is  2 
to  15  grains  (0.12  to  1.0  gram),  the 
average  being  5  grains  (0.3  gram). 

The  aromatic  spirit  of  ammonia 
(spiritus  ammonicB  aromaticus) ,  already- 
considered  under  ammonia  (q.v.),  con- 
tains about  4  per  cent,  of  ammonium 
carbonate. 

MODE  OF  ADMINISTRATION. 
— Ammonium  carbonate  should  not  be 
given  in  any  form  other  than  a  well- 
diluted  solution,  thus  avoiding  excessive 
gastric  irritation  and  facilitating  absorp- 
tion. The  evanescence  of  the  effects  of 
this  salt,  in  common  with  other  ammo- 
nium salts,  requires  that  it  be  frequently 
repeated,  e.g.,  every  two  hours.  Its  un- 
pleasant taste  may  be  covered  by  lico- 
rice. 

INCOMPATIBLE3.— Ammonium 
carbonate  is  incompatible  with  acids, 
with  acid  salts,  and  with  lime  water. 

PHYSIOLOGICAL  ACTION.— 
Ammonium  carbonate  possesses,  to  a 
certain  extent,  the  stimulating  proper- 
ties of  ammonia.  As  has  already  been 
stated,  the  general  stimulant  effect  of 
the  latter,  taken  internally,  is  now  be- 
lieved due  not  so  much  to  a  direct  ac- 
tion of  the  ammonium  group  on  the 
nerve-centers  and  circulation  after  ab- 
sorption as  to  the  irritation  of  the  gas- 
tric mucous  membrane  due  to  the 
strong  alkalinity  of  ammonia.  The 
same  view  is  held  with  regard  to  am- 
monium carbonate,  the  lesser  extent  of 
its  stimulating  effect  corresponding  with 
its  lower  degree  of  alkalinity  as  com- 
pared to  ammonia.  Taken  in  consider- 
able amounts,  the  salt  causes  vomiting. 

If  ammonium  carbonate  is  injected 
subcutaneously  or  intravenously,  direct 
stimulation  of  the  respiratory  and  vaso- 
motor centers,  spinal  cord,  and  heart 
by  the  ammonium  circulating  in  the 
blood  (in  addition  to  the  reflex  stimu- 


lation from  local  irritation,  when  in- 
jected subcutaneously)   is  produced. 

Like  the  acetate  of  ammonium,  the 
carbonate  acts  as  a  mild  diaphoretic 
and  diuretic.  It  possesses  also,  to  a 
considerable  degree,  the  property  of 
increasing  the  bronchial  secretions 
and  mucus  in  general.  After  absorp- 
tion it  is  partly  oxidized  to  urea;  but 
some  of  it  is  excreted  unchanged  by 
the  bronchial  and  other  glands,  which 
are  stimulated  by  it.  According  to 
Sollmann,  ammonium  salts  in  increas- 
ing secretions  of  the  respiratory  tract 
and  the  saliva  act  in  no  less  than  four 
ways:  1.  By  reflex  stimulation  from 
the  mucous  membranes  with  w^hich 
the  salt  is  brought  in  contact.  2.  By 
direct  stimulation  of  the  secretory 
nerve-centers,  which  the  drug  reaches 
through  the  circulation.  3.  By  a  local 
stimulating  action  on  the  gland-cells 
themselves,  with  the  secretions  of 
which  the  salt  is  excreted.  4.  Through 
liquefaction  of  the  mucous  secreted, 
owing  to  the  alkalinity  of  the  am- 
monium carbonate  eliminated  with  it. 
(Several  ammonium,  salts,  besides  the 
carbonate  itself — the  acetate,  citrate, 
etc. — are  converted  in  the  system  into, 
and  partly  eliminated  as,  the  carbonate.) 

Ammonium  carbonate,  like  ammonia, 
is,  to  a  certain  extent,  antiseptic,  owing 
to  its  alkalinity.  Applied  to  the  skin,  it 
acts  as  a  rubefacient. 

The  pure  neutral  carbonate  of  am- 
monium—  (NH4)2C03 — is  of  physio- 
logical importance.  The  nitrogenous 
waste  product  of  the  activity  of  mus- 
cles is  ammonium  lactate.  This,  ac- 
cording to  the  belief  of  some,  is  con- 
verted in  the  tissues  into  ammonium 
carbonate,  which,  in  turn,  is  dehydrated 
in  the  liver  to  ammonium  carbonate, 
and,  finally,  to  urea.  Where  the  hepatic 
functions  are  deficient,  ammonium  car- 


AMMONIUM    (SAJOUS). 


617 


bonate  or  carbamate  may  persist,  and 
cause  symptoms  of  ammonium  poison- 
ing, somewhat  resembling  those  of 
uremia. 

TOXICOLOGY.— Ammonium  car- 
bonate, ingested  in  large  amount,  brings 
about  nausea  and  vomiting  througb 
local  irritation.  If  brought  in  contact 
with  the  mucous  membranes  in  concen- 
trated form,  destructive  lesions,  some- 
what similar  to  those  produced  by  am- 
monia, may  result.  For  symptoms  and 
treatment  the  reader  is  referred  to  the 
section  on  the  toxicology  of  ammonia. 

THERAPEUTICS.— As  an  expec- 
torant, ammonium  carbonate  is  of 
considerable  value.  The  secretions 
are  both  increased  and  rendered  more 
fluid,  being,  therefore,  removed  with 
greater  facility.  In  bronchitis,  pneu- 
monia, asthma,  and  pulmonary  tuber- 
culosis, the  combination  of  the  ex- 
pectorant effect  with  the  stimulating 
action  on  the  respiratory  centers  is  very 
advantageous,  more  especially  in  cases 
where  dyspnea  is  marked.  In  these  af- 
fections it  should  be  given  in  doses  of 
5  or  10  grains  (0.3  to  0.6  gram),  re- 
peated every  two  hours. 

In  acute  coryza  it  may  also  be  em- 
ployed with  satisfactory  results. 

As  a  Stimulant.  —  The  stimulating 
effect  of  this  remedy  on  the  medullary 
centers  and  heart  is  of  great  value  in 
all  conditions  of  general  adynamia, 
w^ith  or  without  involvement  of  the 
respiratory  tract.  In  the  acute  exan- 
themata of  children,  and  continued 
fevers  of  various  kinds,  it  may  be  used 
with  great  advantage  to  sustain  cir- 
culatory and  respiratory  activity.  In 
bronchopneumonia,  chronic  bron- 
chitis Avith  marked  general  weakness, 
it  is  a  favorite  remedy.  In  chronic 
heart  disease  with  failure  of  compen- 
sation it  is  also  frequently  used.     The 


effect  is,  of  course,  of  brief  duration, 
and  frequent  administration  being  re- 
quired to  keep  up  the  action.  In  "faint- 
ing" (syncope)  and  shock  the  inhala- 
tion of  "smelling  salts"  (ammonium 
carbonate  reinforced  with  ammonia 
water)  is  a  time-honored  and  effective 
procedure. 

As  a  Gastric  Stimulant  or  Emetic. 
— In  indigestion  due  to  general  weak- 
ness, and  in  cases  where  flatulence  is 
a  prominent  symptom,  ammonium 
carbonate  may  be  used  to  tone  up  the 
gastric  functions.  Its  effects  are, 
however,  evanescent.  In  the  indi- 
gestion of  alcoholics  it  has  also  proven 
very  useful. 

Emesis  may  be  obtained  by  the  ad- 
ministration of  large  doses,  e.g.,  30 
grains  (2  grams),  of  ammonium  car- 
bonate. The  absence  of  concomitant 
depressing  effects  distinguishes  this 
form  of  emesis  from  that  caused  by  de- 
pressing drugs,  such  as  tartar  emetic. 

As  a  Rubefacient  and  Discutient. — 
Ammonium  carbonate  may  be  em- 
ployed as  a  rubefacient  in  a  manner 
similar  to  ammonia  {q.v.).  In  psori- 
asis, baths  containing  ammonium  car- 
bonate are  given  for  the  purpose  of  dis- 
solving off  the  scaly  coverings  of  the 
lesions,  in  order  that  the  local  remedies 
subsequently  applied  may  act  directly 
on  the  skin. 

AMMONIUM  CHLORIDE,  also 
known  as  "sal  ammoniac"  or  muriate 
of  ammonia,  has  the  chemical  formula 
NH4CI.  It  may  readily  be  produced 
by  the  interaction  of  ammonia  and 
hydrochloric  acid,  but  is  more  usually 
produced  by  neutrahzing  ammonia  with 
sulphuric  acid,  separating  by  crystalli- 
zation the  ammonium  sulphate  thus 
formed,  and  subliming  it  with  sodium 
chloride.  It  occurs  as  a  white,  crystal- 
line powder,  odorless,  but  having  a  cool- 


618 


AMMONIUM    (SAJOUS). 


ing,  saline  taste.  In  contrast  with  am- 
monium carbonate,  ammonium  chloride 
is  permanent  in  the  air.  When  strongly 
heated  it  is  completely  volatilized,  with- 
out decomposition. 

Ammonium  chloride  is  soluble  in  2 
parts  of  water,  in  50  parts  of  alcohol, 
and  in  5  parts  of  glycerin  at  25°  C.  {77° 
F.),  and  in  1  part  of  boihng  water. 
Though  ammonium  chloride  is  a  neu- 
tral salt,  its  solution  in  water  has  a 
slightly  acid  reaction.  This  is  due  to 
the  fact  that  small  amounts  of  NH4OH 
and  of  HCl  are  formed  in  the  solution 
by  reaction  of  NH4CI  with  H2O,  and 
that  the  HCl  is  dissociated  into  its  ions 
to  a  greater  degree  than  the  NH4OH, 
therefore  being  chemically  more  active 
and  producing  the  acid  reaction. 

The  dose  of  ammonii  chloridum  is 
2  to  30  grains  (0.12  to  2.0  grams),  the 
average  being  7)4  grains  (0.5  gram). 
The  trochisci  ammonii  chloridi  (tro- 
ches or  lozenges),  also  official,  each 
consist  of  ammonium  chloride,  0.1  gram 
{iy2  grains);  extract  of  glycyrrhiza, 
0.2  gram  (3  grains)  ;  tragacanth,  0.02 
gram  (^  grain)  ;  sugar,  0.4  gram  (6 
grains),  with  syrup  of  Tolu,  q.  s. 

MODES  OF  ADMINISTRA- 
TION.— Ammonium  chloride  is  best 
given  in  solution  or  in  the  form  of  loz- 
enges. Licorice  is  decidedly  the  most 
advantageous  agent  for  disguising  its 
unpleasant  salty  taste.  The  mistura 
ammonii  chloridi  of  the  National  For- 
mulary, e.g.,  contains  2j4  parts  each  of 
the  salt  and  of  pure  extract  of  licorice 
in  100  parts  of  water.  Similarly,  the 
mistura  glycyrrhijsce  composita  (brown 
mixture)  of  the  U.  S.  P.  is  often  used 
as  a  vehicle  for  ammonium  chloride. 
In  affections  of  the  lower  respiratory 
passages  inhalations  of  freshly  formed 
ammonium  chloride  vapors  are  also  fre- 
quently utilized. 


INCOMPATIBLES.— Ammonium 

chloride  is  incompatible  with  alkaline 
compounds  or  carbonates  of  the 
stronger  alkali  metals, — sodium  and 
potassium, — or  of  the  metals  of  the  al- 
kaline earths, — calcium,  strontium,  ba- 
rium ;  the  more  strongly  basic  metals  in 
these  compounds  tend  to  displace  the 
ammonium  from  its  chloride.  If  an 
ammonium  chloride  solution  to  which 
sodium  or  potassium  hydroxide  has 
been  added  is  heated,  gaseous  ammo- 
nia is  evolved.  Salts  of  silver,  mercury, 
or  lead,  in  solution,  are  precipitated  as 
insoluble  chlorides  if  combined  with 
the  chloride  of  ammonium. 

PHYSIOLOGICAL  ACTION.— 
Taken  internally,  ammonium  chloride, 
being  less  irritating  than  ammonia  or 
ammonium  carbonate,  causes  but  little 
reflex  irritation  of  the  central  nervous 
system  through  irritation  of  the  gastric 
mucosa.  In  view  of  the  fact,  however, 
that  it  is  destroyed  in  the  blood  to  a 
much  less  extent  than  ammonium  car- 
bonate and  ammonium  acetate  (which, 
as  has  already  been  stated,  are  largely 
converted  to  the  relatively  inert  sub- 
stance, urea),  we  would  expect  ammo- 
nium chloride  to  exhibit  the  direct  stim- 
ulating effect  of  ammonium  on  the 
nerve-centers  more  clearly  than  the 
compounds  just  mentioned.  That  this 
is  not  the  case,  ammonium  chloride  be- 
ing but  slightly  a  general  stimulant, 
tends  to  support  the  view,  now  held  by 
many,  that  the  stimulating  effects  of 
ammonium  compounds  taken  internally 
are  exerted  through  a  reflex,  rather 
than  a  direct,  action  on  the  centers. 
Nevertheless,  if  the  salt  be  given  intra- 
venously, the  direct  stimulating  action 
of  ammonium  on  the  spinal  cord,  the 
respiratory,  vasomotor,  and  other  cen- 
ters, as  well  as  the  heart  muscle,  be- 
comes clearly  manifest.    It  may  be  pre- 


AMMONIUM    (SAJOUS). 


619 


Ceded  by  a  period  of  central  nervous 
depression,  as  was  well  illustrated  in 
the  results  obtained  by  Gourinsky  in 
experiments  on  frogs  and  pigeons.  His 
findings  were  these :  In  frogs  whose 
spinal  cord  has  been  divided  below  the 
medulla  oblongata  ammonium  chloride 
produces,  from  the  first,  a  marked  aug- 
mentation of  reflex  action.  In  normal 
frogs  and  pigeons,  on  the  other  hand, 
ammonium  chloride  produces,  at  first, 
depression  of  the  central  nervous  sys- 
tem, then  convulsions ;  the  higher  cen- 
ters at  first  exercise  an  inhibitory  influ- 
ence on  the  spinal  reflexes.  When  the 
salt  is  introduced  rapidly,  the  first  stage 
(that  of  depression)  is  but  slightly 
marked,  and  soon  gives  place  to  the  sec- 
ond stage  (that  of  irritation,  ushered 
in  by  convulsions).  When  it  is  intro- 
duced slowly  the  depression  is  well 
marked  and  lasts  a  long  time.  In  frogs 
and  pigeons  deprived  of  the  cerebral 
hemispheres  only,  whatever  be  the 
method  of  introducing  the  salt,  convul- 
sions are  not  preceded  by  depression, 
but  the  latter  is  sometimes  replaced  by 
irritability.  All  the  facts,  according  to 
Gourinsky,  can  be  explained  only  by 
the  reciprocal  action  of  the  nervous 
centers  on  each  other,  modified  by  the 
ammonium  chloride.  It  should  be  men- 
tioned, in  this  connection,  that,  in  the 
frog,  ammonium  chloride  has  a  ten- 
dency to  paralyze  the  motor  nerve-ter- 
minals in  the  muscles ;  in  mammals, 
however,  this  effect  is  hardly  noticeable, 
even  with  large  doses. 

The  most  important  action  of  ammo- 
nium chloride  is  that  on  the  secretions 
of  the  respiratory  passages,  stomach, 
and  mucous  membranes  in  general, 
which  are  increased  and  rendered  more 
fluid  by  it.  The  several  ways  in  which 
this  effect  may  be  produced  have  been 
set   forth   under  ammonium   carbonate 


(q.2'.).  The  fact  that  some  of  the  salt 
is  eliminated  by  the  mucous  membranes 
suggests  that  the  direct  action  of  the 
drug  on  the  gland-cells  must  play  an 
important  role  in  the  effect  produced. 
Its  elimination  with  the  sweat  and  urine 
also  causes  it  to  be  mildly  diaphoretic 
and  diuretic,  as  well  as  expectorant. 

Ammonium  chloride  has  been  found 
to  produce  an  increase  in  all  the  solids 
of  the  urine,  except  in  uric  acid. 

When  given  continuously  for  some 
time,  it  is  believed  to  cause  pathological 
alterations  in  the  blood,  which  may 
eventuate  in  general  prostration,  to- 
gether with  hemorrhage  under  the  skin, 
from  the  mucous  membranes,  and  hem- 
aturia. 

Externally,  ammonium  chloride,  in 
strong  solutions,  acts  as  an  irritant. 

THERAPEUTICS.— As  a  Stimu- 
lant to  Mucous  Membranes. — In  Dis- 
orders of  the  Respiratory  Tract. — Am- 
monium chloride  has  long  been  consid- 
ered an  effective  remedy  in  almost 
every  disorder  of  the  respiratory  tract. 
More  recently  the  carbonate  has  re- 
placed it  in  the  treatment  of  pulmonary 
disorders,  but  the  chloride  is  still  widely 
used  in  chronic  bronchitis  and  acute 
bronchitis  after  the  initial  stage  of  the 
bronchial  inflammation  has  passed  that 
of  marked  congestion  and  dryness.  In 
whooping-cough,  also,  ammonium  chlo- 
ride has  given  fairly  good  results.  The 
drug  acts,  at  least  in  part,  directly  on 
the  gland-cells  of  the  mucous  mem- 
branes, with  the  secretions  of  which  it 
is  eliminated  into  the  bronchi.  The  cells 
are  stimulated  by  virtue  of  its  "salt 
action,"  the  result  being  a  less  tenacious 
and  more  watery  secretion  of  mucus, 
which  is  more  readily  evacuated.  Fre- 
quently the  drug  is  given  in  combina- 
tion with  other  stimulating  expectorant 
remedies.     In    the    terminal    stage    of 


620 


AMMONIUM    (SAJOUS). 


acute  coryzaand  in  subacute  or  chronic 
forms  of  pharyngitis  and  laryngitis,  the 

beneficial  efifects  of  ammonium  chloride 
on  the  mucous  membranes  are  also  util- 
ized with  advantage. 

In  pneumonia,  ammonium  chloride 
has  been  given  in  10-grain  (0.6  gram) 
doses  every  two  hours,  in  the  hope  of 
in  some  way  favorably  modifying  the 
inflammatory  process  in  the  lung,  but 
the  results  obtained  have  not  been  strik- 
ing  (Brunton). 

Fumes  of  nascent  ammonium  chlo- 
ride, generated  by  the  action  of  hydro- 
chloric acid  on  ammonia,  are  frequently 
administered  by  inhalation  in  respira- 
tory disorders,  and  have  proven  quite 
effective  in  mild  chronic  affections  of 
the  mucous  membranes,  including  bron- 
chitis, pharyngitis,  laryngitis,  etc. 

It  is  a  constituent  of  the  official  mis- 
tura  glycyrrhizcs  composita  (U.  S.  P.), 
of  mistura  ammonii  chloridi  (N.  F.). 

The  value  of  ammonium  chloride 
troches,  or  lozenges,  for  local  stimula- 
tion in  pharyngeal  disorders  is  well 
known.  They  serve  the  double  pur- 
pose of  increasing  local  lubrication  by 
exciting  the  glandular  acini  and  of 
gently  stimulating  the  hepatic  functions 
after  the  salt  has  been  absorbed.  The 
official  ammonium  chloride  lozenge  has 
already  been  referred  to;  1  to  6  or  more 
of  these  lozenges  may  be  taken  daily. 

Ammonium  chloride  solution  has  also 
been  used  in  throat  affections  in  the 
form  of  a  spray. 

In  Aural  Disorders. — The  use  of 
chloride  of  ammonium  vapor  in  affec- 
tions of  the  middle  ear  has  been 
prompted  by  its  effectiveness  in  catar- 
rhal affections  of  the  nasal  mucous 
membrane. 

In  Gastric  Catarrh. — That  ammo- 
nium chloride  is  of  value  in  catarrhal 
disorders  of  the  stomach,  especially  in 


children,  is  indicated  by  the  frequency 
with  which  it  is  still  resorted  to.  Pre- 
sumably, its  chief  action  is  to  loosen  the 
mucous  secretions.  It  may  be  given  in 
solution  or  in  pills ;  if  in  the  latter  form 
a  half-tumblerful  of  pure  water  should 
be  taken  simultaneously  to  prevent  un- 
due irritation  of  the  gastric  mucosa  by 
the  salt.  Instead  of  water,  milk  may 
be  used. 

In  Cystitis. — In  catarrhal  cystitis 
ammonium  chloride  sometimes  proves 
very  effective.  Ten  grains  (0.6  gram) 
every  four  hours  on  the  first  day,  in  a 
tumblerful  of  water,  and  5  grains  (0.3 
gram)  on  the  second  day  and  there- 
after soon  cause  the  local  distress  greatly 
to  diminish. 

As  a  Stimulant  to  the  Liver. — In  all 
conditions  associated  with  torpidity 
of  the  liver,  whether  this  be  due  to  a 
subacute  hepatitis  or  to  general  as- 
thenia, ammonia  chloride,  in  doses 
of  20  grains  (1.3  grams)  three  times 
a  day,  has  been  found  of  great  value. 

In  Alcoholism. — In  alcoholic  intox- 
ication ammonium  chloride  has  been 
said  to  act  as  effectively  as  ammonia. 
Thirty  grains  (2.0  grams),  repeated  in 
half  an  hour,  were  found  to  bring  the 
sufferer  to  his  normal  condition,  in 
so  far  as  the  mental  aberration  was  con- 
cerned. If  emesis  or  lavage  had  been 
resorted  to  before  the  administration  of 
the  salt,  the  action  of  the  latter  was 
greatly  prolonged. 

In  Neuralgia  and  Migraine. — Am- 
monium has  been  found  frequently  to 
afford  considerable  relief  in  these  dis- 
orders, especially  if  given  with  tincture 
of  aconite.  Twenty  grains  (1.3  grams) 
of  the  ammonium  salt  with  2  minims 
(0.12  c.c.)  of  the  tincture,  repeated  twice 
after  the  first  dose,  at  intervals  of  half 
an  hour,  usually  procured  marked  dimi- 
nution of  the  suffering. 


AMYLENE  HYDRATE. 


621 


External  Uses. — In  superficial  in- 
flammatory swellings,  caj.,  buboes, 
mammary  abscesses,  testicular  inflam- 
mations, etc.,  ammonium  chloride  solu- 
tions have  been  applied  locally  with 
benefit. 

In  vaginitis  a  solution  of  3  drams 
(12.0  grams)  of  ammonium  chloride  in 
1  pint  (475  c.c.)  of  water  can  be  used 
as  an  injection  or  applied  on  a  tampon 
with  benefit  (Butler). 
■  A  saturated  solution  of  the  salt  may 
be  used  with  advantage  in  bruises,  to  re- 
duce swelling  and  diminish  discolora- 
tion. The  antiseptic  qualities  of  am- 
monium chloride  in  the  treatment  of 
wounds  have  been  emphasized  by  H.  C. 
Wyman,  who  obtained  good  results,  es- 
pecially in  contused  wounds,  from  the 
use  of  gauze  steeped  in  a  solution  of  1 
ounce  of  the  salt  in  half  a  pint  of 
water.  The  circulation  of  blood  in 
the  injured  parts  also  appeared  to  be 
improved  by  it. 

In  senile  gangrene  a  good  therapeu- 
tic measure  is  to  place  the  foot  in  a  solu- 
tion of  8  ounces  (250  grams)  of  ammo- 
nium chloride  to  1  gallon  (3800  c.c.)  of 
water  (Butler).  It  increases  the  alka- 
linity of  the  blood  and  thereby  its  os- 
motic properties,  and  facilitates  its  cir- 
culation. 

C.  E.  DE  M.  Sajous 

AND 

L.  T.  DE  M.  Sajous, 

Philadelphia. 

AMMONIUM  ICHTHYOL 
GROUP.     See  Ichthyol. 

AMPUTATIONS  and  RESEC- 
TIONS. See  Resections,  Amputa- 
tions, ETC. 

AMYL  NITRITE.    See  Nitrites. 

AMYLENE   CHLORAL.    See 

DORMIOL. 


AMYLENE  HYDRATE.  -  This 

siilistancc  is  chemically  tertiary  amyl 
alcohol  or  dimethylethylcarbinol  [(CH3)2- 
C(C2H.r,)OH].  It  occurs  as  a  colorless, 
volatile,  oily  liquid,  having  an  unpleasant 
ethereal  odor  and  a  burning,  camphor-like 
taste.  It  is  produced  by  the  interaction  of 
amylene,  water,  and  sulphuric  acid.  Its 
specific  gravity  at  ordinary  temperatures 
is  0.820,  and  its  boiling  point  is  99°-103°  C 
It  is  soluble  in  8  parts  of  water  and  mixes 
freely  with  alcohol,  ether,  chloroform, 
and  glycerin.  It  should  be  kept  in  well- 
stoppered  bottles. 

DOSE  AND  MODES  OF  ADMINIS- 
TRATION.— The  dose  of  amylene  hydrate 
taken  by  the  mouth,  for  adults,  is  30  to 
90  minims  (2  to  6  c.c).  If  it  is  to  be  admin- 
istered by  the  rectum,  slightly  larger  amounts 
are  required. 

The  disagreeable  taste  of  amylene  hy- 
drate may  be  avoided  by  enclosing  it  in 
capsules  (15  minims  in  each;  3  capsules 
at  a  dose)  or  by  administering  it  in  fla- 
vored solutions  such  as  the  following: — 

IJ  Amylene  hydrate.   1  dr.    (4  Gm.). 

Water    2  oz.    (60  c.c). 

Orange-flower 

water   2  oz.    (60  c.c). 

Syrup     of     bitter 

orange   1  oz.    (30  c.c). 

M. 

Of  this  one-half  may  be  taken  at  night. 

Where  an  analgesic  effect  is  required  in 
addition  to  the  hypnotic  influence,  mor- 
phine may  be  combined  with  amylene  hy- 
drate, as  in  the  following  formula,  recom- 
mended by  Fisher: — 

IJ  Amylene  hydrate.    1^   drs.    (6  Gm.). 
Morphine     hydro- 
chloride     ^  gr.    (0.015  Gm.). 

Distilled  water  ..  3  oz.    (90  c.c). 
Extract      of     lic- 
orice       2j^    drs.    (10   Gm.) . 

M.  Sig. :  To  be  taken  in  two  doses  two 
hours  apart. 

Amylene  hydrate  may  also  be  given  in 
wine,  beer,  or  brandy.  A  mixture  of  wine 
and  syrup  of  licorice  forms  an  especially 
good  vehicle. 

It  cannot  be  employed  subcutaneously, 
owing  to  the  severe  irritation  and  pain 
produced. 

PHYSIOLOGICAL  ACTION.— Amy- 
lene hydrate,  like  alcohol,  causes  a  primary 
apparent   excitement   followed  by   depres- 


622 


AMYLENE  HYDRATE. 


sion  and  ultimate  paralysis  of  the  nerve- 
centers.  The  brain,  cord,  and  medulla  are 
stimulated  and  depressed  in  succession, 
the  secondary  results  being  sleep,  aboli- 
tion of  reflex  activity,  and  respiratory 
arrest.  In  the  lower  animals  large  doses 
have  been  found  to  induce  cardiac  depres- 
sion and  a  pronounced  fall  in  the  body 
temperature.  The  latter  effect  has  been 
credited  to  a  direct  action  of  the  thermic 
centers.  In  man,  however,  amylene  hy- 
drate in  moderate  doses  does  not  influence 
the  temperature  to  any  degree,  even  in 
fever.  Neither  does  it  depress  to  any 
marked  extent,  except  in  grossly  excessive 
doses,  the  cardiovascular  functions  and 
respiration, — a  feature  in  which  it  is  supe- 
rior to  chloral  hydrate.  Amylene  hydrate 
has  but  little  influence  on  general  metab- 
olism. The  elimination  of  urea  is  said  to 
be  more  or  less  diminished  after  its  in- 
ternal use. 

Locall}^  it  is  somewhat  of  an  irritant. 
Upon  subcutaneous  injection  tissue  necro- 
sis and  abscess  formation  may  result. 

UNTOWARD  EFFECTS;  POISON- 
ING.— According  to  Scharschmidt,  some 
patients  perspire  freely  at  the  beginning 
of  the  effects  of  amylene  hydrate.  Occa- 
sionally excitement  similar  to  that  pro- 
duced by  alcohol  or  slight  degree  of  stupor 
are  produced  by  it.  Headache  and  dizzi- 
ness in  a  few  instances   follow  its   use. 

Four  cases  of  poisoning  from  overdoses 
were  witnessed  by  Dietz.  The  symptoms 
consisted  of  deep  sleep,  from  which  the 
patients  could  not  be  aroused,  complete 
motor  paralysis,  and  loss  of  sensibility, 
including  both  touch  and  pain.  The  pupils 
were  dilated,  and  reacted  but  slowly  to 
light;  the  corneal  reflex  was  abolished. 
Respiration  was  slow,  superficial,  and 
irregular;  the  pulse  small,  soft,  and  in- 
frequent, and  the  temperature,  in  two  in- 
stances, lowered  to  95°  F.  Artificial  res- 
piration was  required  in  one  case.  During 
recovery  mental  confusion  and  motor  in- 
co-ordination  were  conspicuous.  In  each 
case  the  overdose  had  been  taken  through 
neglect  to  shake  the  bottle  in  which  the 
drug  was  mixed  with  syrup.  Dietz  advises 
that  to  avoid  such  accidents  the  drug  be 
administered  in  capsules. 

No  instances  of  amylene-hydrate  habit 
or  cachexia  have  been  observed  (Flint). 


THERAPEUTIC  USES.— Amylene  hy- 
drate was  introdviced  in  medicine  as  a 
hypnotic  by  von  Mehring,  and  has  since 
held  a  favorable  position  as  such,  though, 
as  Cushny  states,  it  "has  not  received  so 
wide  a  trial  as  it  would  seem  to  merit." 
Its  effects  rather  closely  resemble  those 
of  paraldehyde,  but  it  leaves  no  bad  taste 
in  the  mouth  or  disagreeable  odor  on  the 
breath,  such  as  are  noticed  with  paralde- 
hyde after  the  patient  has  awakened.  In 
hypnotic  power  it  is  stronger  than  paralde- 
hyde, but  weaker  than  chloral  hydrate. 
Likewise  it  is  believed  to  exert  a  greater 
depressing  influence  on  the  heart  than 
paraldehyde, — though  less  than  chloral 
hydrate.  Kirby  and  Griffith  recommended 
that  this  drug  be  always  used  in  heart 
disease  in  place  of  chloral.  They  also 
stated  that  in  their  experience  amj'lene 
hydrate  did  not  lose  its  efficiency  upon 
continued  use, — though  given  during  three 
months  in  some  cases, — and  that  the  deep 
and  refreshing  sleep  produced  by  the 
drug  was  praised  by  patients  oftener  than 
in  the  case  of  any  other  hypnotic. 

Amylene  hydrate  differs  in  its  action 
from  chloral  in  that  it  does  not  increase 
nitrogenous  wastes.  According  to  Peiser 
the  quantity  of  nitrogen  eliminated  by  the 
urine  after  amylene  hydrate  is,  in  fact, 
lessened.  This  author  therefore  prefers 
the  drug  to  chloral  whenever  the  hypnotic 
effects  are  to  be  continued  for  a  long  time 
and  in  all  affections  associated  with  an 
exaggerated  decomposition  of  albumins, — ■ 
in  fever,  in  anemia,  pulmonary  tuber- 
culosis, and  diabetes. 

Sleep  follows  the  ingestion  of  amylene 
hydrate  much  more  promptly  than  after 
sulphonal,  and  it  does  not  tend,  as  does 
the  latter,  to  produce  drowsiness  and 
giddiness  on  the  following  day. 

On  the  whole,  amylene  hydrate  is,  ac- 
cording to  Kirby  and  Griffith,  a  reliable 
hypnotic  if  given  in  sufficient  dose,  though 
it  is  somewhat  less  certain  in  effect  than 
chloral  or  morphine.  When  given  by  the 
rectum  (in  an  enema  with  gum  arabic  and 
water),  amylene  hydrate  brings  on  sleep 
in  fifteen  to  forty-five  ininutes,  or  even 
sooner,  though  occasionally  it  fails  entirely 
to  do  so. 

Amylene  hydrate  acts  satisfactorily  in 
insomnia  associated  with  nervousness,  ex- 


AMYLOFORM. 


623 


cessive  mental  strain,  fevers,  and  anemia. 

Its  usefulness  in  cardiac  states  has  already 
been  referred  to. 

In  gastric  disorders  its  oral  use  is  apt 
to  result  in  local  irritation  and  nausea;  in 
such  cases  it  should  be  administered  by  the 
rectum.  It  is  less  irritating  to  the  rectal 
mucous  membrane  than  chloral  hydrate. 

In  the  insomnia  of  mental  diseases,  amy- 
lene  hydrate  has  seen  extensive  service. 
In  a  series  of  149  cases  Lehmann  obtained 
good  results  with  it.  In  mania  large  doses 
were  required.  Cases  of  paralysis  of  the 
insane  were  benefited,  but  in  the  insomnia 
of  melancholia  it  was  less  effective.  It 
proved  to  be  more  efficacious  and  less  un- 
pleasant than  paraldehj^de. 

Avellis  found  amjdene  hydrate  generally 
effective  in  alcoholic  delirium. 

In  a  case  of  opium  addiction  in  which 
chloral,  bromides,  paraldehyde  and  hyos- 
cine,  singly  or  variously  combined,  had 
given  indifferent  results,  amylene  hydrate 
produced  sleep  lasting  through  the  night 
with  but  little  or  no  intermission  (Kirby 
and  Griffith).  Like  results  have  been 
noted  by  other  observers. 

In  pulmonary  disorders,  G.  Mayer  found 
amylene  hydrate  not  only  to  produce 
sleep,  but  apparently  to  exert  a  decided 
sedative  influence  on  the  cough.  In  tuber- 
culosis it  sometimes  proved  useful  in  this 
respect  after  morphia  had  had  but  little 
effect.  When  there  was  pain  or  very 
troublesome  cough,  however,  it  was  not 
uniformly  successful.  S. 

AMYLOFORM.— Amyloform     is     a 

condensation  product  of  formaldehyde  and 
starch,  first  prepared  by  Classen,  of 
Aachen,  in  1896.  It  occurs  in  the  form  of 
very  fine,  white,  odorless,  and  tasteless 
powder,  which  is  insoluble  in  ordinary 
solvents.  It  remains  undecomposed  at  a 
temperature  of  180°   C. 

PHYSIOLOGICAL  ACTION.— Amylo- 
form is  but  slightly  irritating.  It  is 
strongly  antiseptic,  disinfectant,  deodor- 
ant, and  absorbent,  and  is  said  to  have  all 
the  advantages  of  iodoform  without  pos- 
sessing its  disagreeable  odor.  When  ap- 
plied to  living  tissue  it  is  broken  up  into 
its  two  components, — formaldehyde  and 
starch, — as  shown  by  the  fact  that  formal- 
dehyde  can   be   detected   in   the   purulent 


discharge  from  suppurating  wounds  to 
which  it  has  been  applied  (Classen).  No 
symptoms  of  general  intoxication  are  pro- 
duced by  the  application  of  amyloform, 
though  temporary  smarting  sensation 
locally  is  sometimes  complained  of.  The 
secretions  from  open  surfaces  are  rapidly 
checked  by  it. 

THERAPEUTIC  USES.— The  drug  is 
employed  either  as  a  dusting  powder  or  in 
an  ointment.  Its  uses  are  much  the  same 
as  those  of  iodoform.  Bongartz  employed 
it  with  success  in  cases  of  deep  wounds 
with  bone  suppuration  and  in  varicose 
ulcers  of  the  leg.  Heddaeus  laid  stress  on 
its  rapid  disinfecting  action  on  tuberculous 
lesions.  Its  most  important  use,  accord- 
ing to  this  author,  is  in  the  treatment  of 
superficial  suppurative  affections.  Lou- 
gard  and  Beauchamp  used  the  drug  in 
numerous  cases  of  phlegmon,  abscess,  fu- 
runcle, etc.,  including  gynecologic  affec- 
tions. Krabbel,  who  tested  it  both  bac- 
teriologically  and  clinically,  came  to  the 
conclusion  that  amyloform  was  in  no  way 
inferior  to  iodoform  as  an  antiseptic.  C. 
L.  Schleich,  however,  contends  that  it 
holds  fre.e  starch,  which  smears  up  the 
wound  and  greatly  hinders  favorable 
action  of  the  formaldehyde  it  contains. 

Contrary  to  iodoform,  amyloform 
can  be  sterilized  in  dry  or  moist  heat 
without  being  decomposed.  Because 
of  this  property,  amyloform  gauze 
affords  some  assurances  of  asepsis 
which  are  not  found  in  the  other 
antiseptic  gauzes.  An  emulsion  for 
preparing  amyloform  gauze  is: — 

B  Amyloform.. 7S  grs.  to  2^  drs.    (5-10  Gm.). 

Glycerin    ...2^  drs.   (10  Gm.). 

Alcohol   ....12^  drs.    (50  Gm.). 

Ether    10  drs.    (40  Gm.). 

01.   ricini    ..  7^^  mins.    (0.5  Gm.). 

The  indications  for  amyloform  are 
the  same  as  for  iodoform.  (Presse 
med.,  Sept.  15,  1900.) 

Good  results  obtained  with  amylo- 
form. The  writers  prefer  it  to  the 
latter  drugs  in  incised  abscesses, 
ulcers,  wounds,  burns,  and  purulent 
otorrhea.  Besides  being  harmless 
and  free  from  any  compromising 
odor,  it  remarkably  hastens  cicatriza- 
tion. Cipriani  (Monats.  f.  prakt.  Der- 
mat.,  Oct.  15,  1900). 


624 


AMYL   VALERATE. 


ANALGEN. 


Amyloform  used  in  fresh  and  neg- 
lected wounds,  ulcers  of  the  leg, 
excoriations,  intertrigo,  felons,  car- 
buncles, osteomyelitis,  tuberculous 
ulcerations,  etc.  The  pure  powder 
usually  employed.  This  occasions 
slight  burning  in  sensitive  patients, 
which,  however,  disappears  soon. 
The  chief  features  of  its  action  are 
that  it  hastens  granulation,  diminishes 
secretion,  and  is,  as  a  rule,  non-irri- 
tating. Its  freedom  from  odor  and 
toxic  effect  is  also  noteworthy.  A. 
Gerlach  (Therap.  Monats.,  Bd.  xvi, 
Nu.  10,  1902).  S. 

AMYL  VALERATE  (Amyl  Vale- 
rianate). — This  is  the  isoamyl  ester  of  iso- 
valeric acid,  and  is  a  reaction  product  of 
amyl  alcohol  with  sulphur  and  valeric 
acids.  It  represents  the  odoriferous  prin- 
ciple of  the  apple,  and  occurs  as  a  color- 
less liquid  of  specific  gravity  0.858  and 
boiling  point  190°  C.  (374°  F.).  It  is  in- 
soluble in  water,  but  dissolves  in  alcohol, 
ether,  and  chloroform.  When  in  dilute 
solution,  its  ethereal  apple-like  odor  is 
plainly  evident. 

PHYSIOLOGICAL  ACTION.— Cider 
has  long  been  believed  by  the  laity  to 
exert  some  favorable  effect  on  calculous 
formations,  and  this  seems  to  be  borne 
out  by  the  fact  that  amyl  valerate  actually 
does  possess  a  certain  solvent  power  with 
reference  to  cholesterin.  Fifteen  grains  of 
cholesterin  are  dissoVed  by  70  grains  of 
amyl  valerate  at  99°  F.,  and  by  46  grains 
at  104°  F.  Where  the  amount  of  choles- 
terin present  exceeds  the  dissolving  power 
of  the  valerate,  it  is,  nevertheless,  greatly 
softened, — to  the   consistency  of  gelatin. 

The  ingestion  of  amyl  valerate  induces 
primary  general  excitation  and  accelera- 
tion of  the  pulse,  followed  by  somnolence 
(Pouchet).  In  addition  to  modifying  or 
dissolving  cholesterin,  it  tends  to  relax 
the  bile-duct  when  in  spasm. 

THERAPEUTIC  USES.— Amyl  vale- 
rate was  introduced  by  Blanc  as  an  anti- 
spasmodic for  use  in  hepatic  and  renal 
colic,  and  as  a  solvent  for  cholesterin  cal- 
culi. It  is  said  in  hepatic  colic  not  only  to 
overcome  the  acute  attack,  but  to  prevent 
recurrences.  No  solvent  effect  on  renal 
calculi   is,    however,   claimed   for   it.     The 


drug  is  administered  in  capsules;  a  cap- 
sule containing  2  to  6  minims  (0.12  to 
0.4  c.c.)  may  be  given  every  half-hour,  or 
one  containing  a  somewhat  larger  amount, 
three  times  daily.  The  use  of  amyl  vale- 
rate should  be  continued  for  some  days 
after  the  acute  disturbance  has  subsided. 

Amyl  valerate  has  also  been  employed 
in  muscular  rheumatism,  in  dysmenorrhea, 
and  as  a  sedative  in  hysteria.  S. 

ANALGEN  (quinalgen;  labordin)  is, 
chemically,  the  benzoylamido  derivative 
of  orthoethoxyquinoline  [C9H5.(OC2H5)- 
N.H.(C0.CcH.5)N].  It  bears  the  same 
relation  to  quinoline  as  acetphenetidin 
does  to  benzene,  with  the  exception  that 
in  analgen  the  benzoyl  group  takes  the 
place  of  the  acetyl  in  acetphenetidin. 
With  the  exception  of  thallin  and  ther- 
mifugin,  it  is  the  only  member  of  the 
quinoline  group  of  coal-tar  analgesics  or 
antipyretics  which  is  still  occasionally  pre- 
scribed. It  occurs  in  the  form  of  color- 
less, tasteless  crystals,  soluble  in  hot  alco- 
hol and  in  acidulated  water,  slightly  so  in 
cold  alcohol,  and  insoluble  in  pure  water. 

PHYSIOLOGICAL  ACTION.— Anal- 
gen possesses  the  same  antipyretic  and 
analgesic  properties  as  acetphenetidin,  and 
its  mode  of  action  is  .closely  similar  (v. 
Acetphenetidin).  With  large  doses,  the 
same  circulatory  depressant  tendency  is 
present  as  with  other  coal-tar  drugs. 
Analgen  is  more  toxic  than  acetphenet- 
idin, though  less  so  than  acetanilide.  It 
is  the  least  dangerous  of  the  quinoline 
derivatives. 

Analgen  given  experimentally  to  mam- 
mals induces  motor  depression  and  dimin- 
ished reflex  response,  followed,  with  toxic 
doses,  by  cyanosis  and  convulsive  move- 
ments. 

The  effects  of  analgen,  when  it  is  in- 
gested, begin  only  after  the  benzoyl  group 
in  it  has  been  set  free  by  the  gastric  juice. 
Its  action  is,  therefore,  somewhat  slower 
in  appearing  than  is  the  case  with  ace- 
tanilide and  antipyrin,  and  is  to  a  certain 
extent  inconstant. 

A  special  feature  of  the  action  of  anal- 
gen is  that  in  large  doses  or  upon  con- 
tinued use  it  produces  a  reddish  discolora- 
tion of  the  urine.  This  coloration,  when 
slight,    is    rendered   more    marked   by   the 


ANEMIA,    PERNICIOUS    PROGRESSIVE    (HENRY). 


625 


addition  of  acetic  acid  (1  to  10).  Accord- 
ing to  some,  the  coloration  is  due  merely 
to  the  presence  of  decomposition  products 
of  analgen  in  the  urine;  according  to 
Moncorvo,  on  the  other  hand,  it  is  due  to 
blood-coloring  matter. 

THERAPEUTIC  USES.— The  average 
dose  of  analgen  for  adults  is  lYi  grains 
(0.5  Gm.).  According  to  Goliner,  the 
maximum  single  dose  is  15^4  grains  (1.0 
Gm.)  and  the  maximum  daily  amount  45 
grains  (3  Gm.).  The  drug  has  been  used 
chiefly  as  an  antineuralgic  and  antipyretic. 
Of  late  its  use  has,  however,  greatly 
diminished,  the  official  drugs  acetanilide, 
antipyrin,  and  acetphenetidin  meeting  with 
greater  favor.  Besides,  the  use  of  any  anti- 
pyretic has  justly  lost  favor. 

Scholkow,  Foy,  Spiegelberg,  and  Maas 
found  analgen  effective  in  a  large  number 
of  cases  of  neuralgia.  According  to  Foy, 
who  used  it.  in  200  patients,  the  full  dose 
of  15  grains  (1.0  Gm.)  was  necessary  to 
produce  relief.  In  the  pains  of  tabes,  zona, 
and  hysteria,  the  results  were  less  brilliant, 
but  in  acute  articular  rheumatism  and  mus- 
cular rheumatism  distinct  benefit  was 
noted  in  many  instances.  According  to 
Maas,  patients  suffering  from  pulmonary 
tuberculosis  experience  "a  peculiar  feel- 
ing of  well-being"  from  its  use.  Moncorvo 
used  analgen  in  59  children,  33  of  them 
presenting  various  malarial  manifestations, 
with  satisfactory  results.  It  was  readily 
taken,  because  tasteless,  and  in  no  instance 
exerted  any  unfavorable  action  of  the  cir- 
culation or  respiration.  The  urine  became 
colored  a  deep  yellow  or  red,  but  albumin 
and  sugar  were  never  detected.  It  acted 
satisfactorily  as  a  sedative  in  chorea, 
hysteria,  and  partial  epilepsy  and  was 
found  useful  to  relieve  pain  of  various 
kinds,  including  that  of  Pott's  disease  and 
hip-joint  tuberculosis. 

Occasional  instances  of  untoward  sec- 
ondary effects  are  recorded  by  Scholkow 
and  Spiegelberg,  including  headache,  tin- 
nitus, nausea,  diarrhea,  and  tremor.  Pa- 
tients taking  analgen  should  be  informed 
of  the  red  discoloration  likely  to  appear 
in  the  urine,  lest  they  be  unduly  frightened 
thereby.  S. 

ANEMIA.  See  Anemia,  Sec- 
ondary. 


ANEMIA,  PERNICIOUS  PRO- 
GRESSIVE. —  DEFINITION.  —  A 

form  of  secondary  anemia  character- 
ized by  a  progressive  destruction  of 
the  red  corpuscles  which  tends  toward 
a  fatal  issue. 

SYMPTOMATOLOGY.— Per- 
nicious anemia  develops  insidiously, 
though  an  abrupt  onset  occasionally  oc- 
curs, especially  in  pregnant  or  puerperal 
women.  The  most  evident  symptom  is 
pallor  of  the  face  and  body,  which 
gradually  becomes  extreme  and  as- 
sumes a  lemon-yellow  tint.  This  yel- 
lowish color  deepens  as  the  case  pro- 
gresses ;  it  may  appear  suddenly,  but  in 
the  majority  of  cases  it  develops  grad- 
ually, following  the  insidious  course  of 
the  disease.  The  mucous  membranes 
are  similarly  affected. 

There  is  great  weakness  with  all  its 
attending  symptoms :  inordinate  palpi- 
tations and  dyspnea  on  exertion,  sigh- 
ing, and  slow  delivery  in  speaking.  The 
pulse,  which  may  be  strong  at  first,  is 
regular,  but  rapid,  soft,  and  compress- 
ible, in  the  majority  of  cases,  more  or 
less  fever  being  usually  present.  The 
temperature  is  extremely  irregular. 
Slight  evening  pyrexia  is  seldom  absent 
in  advanced  cases. 

Cardiac  murmurs,  especially  of  the 
hemic  type,  are  usually  to  be  heard,  es- 
pecially at  the  base,  and  signs  of  fatty 
degeneration  may  be  detected  by  aus- 
cultation, although  there  is  usually  no 
arterial  degeneration  or  valvular  dis- 
ease. A  loud  venous  hum  can  some- 
times be  detected  in  the  vessels  of  the 
neck,  the  so-called  hridt  de  diable  with 
exaggerated  cardiac  impulse.  Edema 
of  the  ankles,  face,  and  lungs  and  drop- 
sical effusions  may  appear  at  any  stage. 

Retinal  hemorrhage  is  a  symptom  of 
great  value.  The  ophthalmoscope  may 
thus  reveal  the  cause  of  the  so-called 


1—40 


626 


ANEMIA,    PERNICIOUS    PROGRESSIVE    (HENRY). 


"anemic  amaurosis"  observed  in  these 
cases,  though  the  whites  of  the  eyes  are 
pearly  and  the  conjunctivae  pale.  There 
may  also  be  hemorrhages  into  the 
mucous  membranes,  epistaxis,  menor- 
rhagia,  and  purpuric  eruptions  in  ad- 
vanced cases.  Ecchymoses  in  the  skin 
and  mucous  membranes  are  sometimes 
noticeable  in  advanced  cases. 

Retinal  hemorrhages  are  also  wit- 
nessed. 

In  the  diagnosis  of  pernicious  anemia 
examination   of  the   retina  is   of  great 


Fundus  oculi  in  a  case  of  pernicious  anemia, 
showing  retinal  hemorrhages.   {Bramwell. ) 

value,  especially  in  those  cases  in  which 
the  blood-picture  is  indefinite.  In  about 
47  out  of  SO  cases  of  pernicious  anemia, 
retinal  hemorrhages  were  found  to  be 
present;  while  in  51  cases  of  severe 
secondary  anemia,  in  which  the  hemo- 
globin was  below  50  per  cent,  and  in 
121  cases  with  a  hemoglobin  of  50  per 
cent,  to  70  per  cent.,  retinal  hemor- 
rhages were  never  found.  In  72  in- 
stances of  malignant  tumor  (43  of  car- 
cinoma and  29  of  gastric  carcinoma)  in 
which  there  is  especially  liable  to  be 
confusion  with  pernicious  anemia,  the 
writer  never  saw  retinal  hemorrhages. 
Not  only  does  the  presence  of  hemor- 
rhages favor  the  pernicious  type  of 
anemia,  and  their  continued  absence  a 
secondary    anemia,    but    they    are     of 


prognostic  importance  as  well.  The 
retinal  hemorrhages  are  larger  and 
more  numerous  in  the  severe  cases; 
and  clearing  up  of  the  hemorrhages  is 
one  of  the  earliest  indications  of  be- 
ginning improvement.  Hesse  (Deut. 
med.  Woch.,  Aug.  12,  1909). 

Gastric  and  intestinal  disorders  are 
the  rule,  although  the  general  nutrition 
is  apparently  preserved,  the  appetite 
being  sometimes  voracious,  and  the  pa- 
tient becoming  obese.  Nausea  is  fre- 
quently an  early  symptom.  Dyspepsia, 
vomiting,  and  diarrhea  usually  prevail, 
though  some  cases  suffer  from  consti- 
pation. The  gastric  region  is  tender  to 
pressure,  and  the  tongue  is  pale  and 
smooth.  Eructations  and  anorexia  are 
common.  Involvement  of  the  osseous 
system  is  occasionally  indicated  by  sen- 
sitiveness of  the  bones,  especially  those 
of  the  sternum. 

The  respiration  is  usually  acceler- 
ated, and  dyspnea,  air-hunger,  and  op- 
pression in  the  chest  are  frequent 
symptoms.  Pericardial  and  pleural  ef- 
fusions are  sometimes  observed. 

Drowsiness  is  present  in  the  major- 
ity of  cases,  but  insomnia  is  occasion- 
ally noted.  The  patient  is  readily 
fatigued  and  even  exhausted  on  the 
least  exertion.  The  weakness  increases 
until  attacks  of  faintness  supervene. 
The  patient  ultimately  becomes  bed- 
ridden. 

Headache,  vertigo,  tinnitus,  apo- 
plectiform attacks,  delirium,  and  other 
disorders  of  the  nervous  system,  such 
as  paresthesia,  neuralgia,  and  extensive 
paralyses,  have  been  noted.  Mental 
torpor,  somnolence,  peevishness,  con- 
fusion, delirium,  and  various  psychic 
phenomena  may  also  occur. 

Case  in  which  there  were  not  only 
symptoms  of  spinal  cord  disease,  but  a 
peculiar  psj'chosis  existing  as  well  in 
connection  with  the  pernicious  anemia, 


ANEMIA,    PERNICIOUS    PROGRESSIVE    (HENRY). 


627 


Changes  in  the  psychic  function  have 
seldom  been  mentioned  in  relation  with 
pernicious  anemia.  Disturbances  as  a 
result  of  a  mere  anemia,  such  as  lowered 
mental  capacity,  occur,  according  to 
Strumpcll.  Consciousness  is  retained, 
but  the  mental  processes  are  dull  and 
apathetic.  In  most  textbooks  of  psy- 
chiatry anemia  is  given  as  an  important 
cause  of  various  psychoses,  especially 
of  mental  confusion  and  delirium. 
Mental  disturbances,  other  than  indo- 
lence, apathy,  and  somnolence,  except 
delirium  just  before  death,  have  not 
been  mentioned.  Henry  Marcus  (Neu- 
rol. Centralbl.,  May  16,  1903). 

A    number    of    patients    have    been 
observed    whose   chief    symptoms    were 
of    a    distinctly    mental    and    nervous 
character,    but    who    in    the    course    of 
time  were   found  to  present  the   char- 
acteristic  blood    conditions    and   bodily 
signs   of  pernicious   anemia.     In   some, 
the  nervous   and  mental   symptoms   ap- 
peared to  be  secondary  to,  in  others  to 
precede  the  development  of,  the  anemia. 
Clinically,  these  cases  collectively  have 
seemed  to  present  a  rather  characteris- 
tic syndrome,  the  principal  features  of 
which   are    as    follows :      1.  General    ill 
health.     2.  Mental    symptoms,    viz.,    in- 
termittent attacks  of  loss  of  inhibition, 
peevishness,     and    gradual    mental     de- 
terioration.      3.  Sensory     disturbances: 
(o)   Subjective,  consisting  of  intramus- 
cular and  articular  dull  aches  and  pains, 
seldom    accompanied    by    effusion    and 
never     by     true     inflammatory     action. 
With  these,    and   perhaps    rather   more 
frequent,    are    sensations   of   numbness, 
tingling,  and  weight  in  the  extremities, 
especially  the  legs,     (b)   Objective  sen- 
sory disturbances:     These  are  common 
and  consist  in  patchy  losses  of  pain  and 
tactile    sensibility    about    the    feet    and 
ankles.     Sometimes  there  may  be   only 
retardation  of  sensation  at  first.    Tabes 
is  excluded  by  the   other  positive   and 
negative     symptoms.       4.       Plus     knee 
jerks,   ankle   clonus,   and   the   Babinski 
sign  are  sometimes  present.     5.  Ataxia 
of  gait  and  station  is  often  present.     6. 
Diarrhea  of  the  mucous  types  is  apt  to 
occur  sooner  or  later.     7.  The  peculiar 
lemon-yellow  tint  of  pernicious  anemia 


occurs  in  the  later  stages.  A  combina- 
tion of  all  these  signs  or  a  majority  of 
them  should  suggest  the  possibility  of  a 
pernicious  or  prepernicious  anemia,  and 
a  careful  blood  examination  may  then 
confirm  the  diagnosis.  Eight  cases 
more  or  less  typical  of  the  condition 
are  reported.  F.  W.  Langdon  (Jour. 
Amer.  Med.  Assoc,   Nov.  25,   1905). 

Absence  of  the  knee-jerk  is  frequent, 
and  is  indicative  of  degeneration  of  the 
posterior  columns  of  the  cord. 

Jaundice  is  occasionally  met  with. 
The  urine  is  dark  and  highly  colored; 
it  is  of  low  specific  gravity,  and  shows 
an  increase  of  urea  and  uric  acid  and 
pathological  urobilin.  Indican  may  also 
be  detected. 

When  the  end  is  approaching,  the 
temperature,  which  in  the  course  of  the 
disease  is  apt  to  rise  toward  evening, 
sometimes  reaching  as  high  as  102°  F. 
(38.8°  C),  recedes  markedly,  and  the 
patient  enters,  into  a  torpid  condition 
ending  in  coma. 

BLOOD  EXAMINATION.  — Be- 
fore  describing   all   the    characteristics 
of  the  blood,  a  summary  of  its  morbid 
changes    may    prove   useful.      Though 
sometimes  dark  and  watery,  the  blood 
is,  as  a  rule,  pale.     The  red  corpuscles 
are  greatly  reduced,  sometimes  as  low 
as  143,000,  though,  as  a  rule,  they  do 
not  go  below  500,000.     The  percentage 
of  hemoglobin  is  also  greatly  reduced, 
but  not  in  proportion  with  that  of  the 
red  corpuscles.    The  latter  also  show 
considerable     alteration     in     size    and 
shape.      Some    are    large    and    ovoid 
(megalofytes)  ;  others  are  small,  round, 
and  dark  red  (microcytes),  while  oth- 
ers again  are  very  irregular  in  shape 
(poikilocytes).      Nucleated    red    cells, 
both  normoblasts  (normal  in  size)  and 
megaloblasts    (when    very    large),    are 
a  marked  characteristic  of  the  disease, 
while  blood-plaques   are   either   absent 


628 


ANEMIA,    PERNICIOUS    PROGRESSIVE    (HENRY). 


or  present  in  very  small  number.  The 
leucocytes,  though  relatively  increased 
in  respect  to  the  red  corpuscles,  are 
usually  normal  in  number,  with  the 
smaller  mononuclear  forms  predom- 
inating. 

To  understand  these  blood  changes, 
however,  they  must  be  analyzed  from 
the  standpoint  of  their  cause.  The  two 
prevailing  theories  as  to  the  pathogen- 
esis of  pernicious  anemia  are:  1.  That 
the  disease  is  due  to  breaking  up  of 
the  blood-corpuscles  (hemolysis).  2. 
That,  owing  to  some  defect  in  the 
blood-making  (hemogenesis), the  blood 
becomes  vulnerable  to  the  destructive 
influence  of  micro-organisms.  At  the 
present  time  the  former  view  strongly 
prevails,  the  hemolysis,  as  urged  by 
Grawitz,  Hunter,  Stengel,  and  others, 
being  ascribed  in  great  part  to  poisons 
absorbed  from  the  alimentary  canal, 
the  disease  being  thus  an  autointoxica- 
tion. The  toxics,  according  to  Sajous, 
promote  and  sustain  hemolysis  by  caus- 
ing an  overproduction  of  antibodies, 
which  not  only  destroy  the  pathogenic 
poisons,  but  also  the  red  corpuscles. 

By  the  subcutaneous  injection  of  the 
muriate  of  phenjdhydrazin  into  animals 
a  condition  of  the  blood  similar  to  that 
in  pernicious  anemia  is  obtained.  S. 
Kaminer  and  R.  Rohnstein  (Berl.  khn. 
Woch.,  July  30,  1900). 

Pernicious  anemia  is  probably  due  to 
an  intoxication,  possibly  from  the 
stomach,  and  the  cases  referred  to  are 
probably  to  be  placed  in  the  same 
category.  It  is  easily  understood  that 
with  an  absence  of  free  hydrochloric 
acid  enormous  bacterial  growth  can 
take  place  in  the  intestines,  and  that 
changes  in  the  digestion  of  the  proteids 
will  follow.  The  treatment  of  the  con- 
dition is  self-explanatory.  Grawitz 
(Berl.  klin.  Woch.,  June  29,  1903). 

Pernicious  anemia  is  a  definite  hemo- 
lytic disease  \^'ith  disturbances  of  the 
alimentary  canal  and  fever.    The  course 


of  the  disease  is  marked  not  only  by 
slight  variations  from  time  to  time,  but 
usually  by  one  or  more  periods  of  dis- 
tinct improvement,  lasting  sometimes 
many  months,  in  some  cases  even  a 
year  or  two — sometimes  occurring  in- 
dependently of  treatment,  but  without 
doubt  greatly  due  to  the  beneficial  effect 
of  arsenic.  The  tendency  to  relapse  is 
in  reality  due  to  the  remarkable  per- 
sistence of  the  specific  hemolytic  infec- 
tion underlying  the  disease,  since  it  is 
always  accompanied  by  a  recrudescence 
of  the  lesions  in  the  tongue,  stomach,, 
or  intestine,  and  by  the  glossitic,  gas- 
tric, or  intestinal  symptoms  connected 
therewith.  Hunter  (Brit.  Med.  Jour., 
Nov.  9,  1907). 

In  an  attempt  to  isolate  a  hemolj'tic 
substance  from  the  stools  of  patients 
suffering  from  pernicious  anemia  with 
ulceration  of  the  intestines,  the  authors 
studied  the  stools  from  106  cases,  all 
but  11  of  which  showed  some  gastro- 
intestinal lesion.  A  hemolytic  substance 
was  constanth^  found  in  the  stools  of 
patients  suffering  with  tuberculous  en- 
teritis (10  ovit  of  11  cases),  while  nor- 
mal cases  gave  practically  negative  re- 
sults. The  hemol3i;ic  substance  appears 
in  the  stools  whenever  there  is  a  dis- 
turbance of  fat  absorption.  Grafe  and 
Rohmer  (Deut.  Archiv  f.  klin.  Med., 
Bd.  xcvi,  S.  397,  1909). 

Deficiency  of  red  corpuscles  (oligo- 
cythemia) is  always  very  great;  the 
blood  is,  therefore,  pale  and  thin,  re- 
sembling sherry  wine.  The  oligocy- 
themia is  sometimes  so  marked  that  the 
normal  proportion  of  5,000,000  red 
corpuscles  to  the  cubic  centimeter  is 
reduced  to  one-twenty-fifth  of  that 
number.  Quincke  reported  a  case  in 
which,  as  previously  stated,  there  were 
only  143,000  to  the  cubic  centimeter 
immediately  before  death.  This  is  an 
important  diagnostic  feature.  There  is 
no  disease,  except  pernicious  anemia, 
in  which  the  number  of  red  corpuscles 
is  at  any  time  reduced  below  20  per 
cent.  This  affords  a  distinction  between 


ANEMIA,   PERNICIOUS   PROGRESSIVE    (HENRY). 


629 


pernicious  anemia  and  latent  gastric 
cancer,  a  disease  with  which  the  former 
is  most  hkely  to  be  confounded. 

The  hemoglobin  is  also  greatly  re- 
duced (oligochromemia),  but  not  in 
proportion  with  the  cell  reduction.  The 
hemoglobin  percentage  was  greater  by 
10  per  cent,  in  a  case  seen  by  Osier. 
The  relatively  high  percentage  of  hem- 
oglobin depends  upon  increased  aver- 
age size  of  the  corpuscles  and  in  some 
cases  on  the  presence  of  an  unusual 
number  of  highly  colored  and  minute 
microcytes.  It  also  depends,  in  a  meas- 
ure, upon  the  time  at  which  the  ex- 
amination is  made.  The  icteric  color 
of  the  skin  and  the  dark  urine  are 
caused  by  dissolution  of  the  red  blood- 
corpuscles,  and  the  hemoglobin  esti- 
mated at  one  of  these  periods  will  thus 
be  higher,  owing  to  the  more  highly 
colored  plasma.  The  red  blood-cor- 
puscles show  marked  signs  of  reversion 
tq  the  type  of  blood  which  is  normal 
in  the  cold-blooded  animals. 

There  is  also  a  species  of  degenera- 
tion closely  resembling  coagulation  ne- 
crosis, and  an  alteration  of  the  cor- 
puscles, characterized  by  the  appearance 
in  their  interior  of  certain  corpuscles 
composed  of  modified  hemoglobin — 
degeneration  hemoglobinemique. 

The  process  of  regeneration  is  man- 
ifested by  the  presence  of  nucleated 
red  corpuscles,  which  are  divided  by 
Ehrlich  into  two  varieties :  the  normo- 
blasts and  the  megaloblasts,  the  former 
corresponding  to  the  hematinic  evolu- 
tion of  adults,  the  latter  to  that  of  the 
embryo.  The  nucleus  of  the  normo- 
blast is  extruded  to  form  a  new  red 
corpuscle,  while  the  nucleus  of  the  meg- 
aloblast  is  absorbed.  Fresh  blood 
shows  nucleated  red  corpuscles  of  large 
size,  the  megalocytes  and  gigantocytes 
previously  mentioned. 


Fiirbringer  has  shown  that  a  case  is 
to  be  considered  as  one  of  true  per- 
nicious anemia  only  when  one-fourth 
of  the  red  corpuscles  are  macrocytes. 
The  presence  of  megaloblasts  is  a  sign 
that  certain  pathological  changes  are 
taking  place  in  the  red  marrow  rather 
than  a  distinctive  feature  of  pernicious 
anemia.  The  macrocytes  are  more 
characterisic  of  pernicious  anemia,  be- 
cause they  are  the  direct  precursors  of 
the  large  red-marrow  cells. 

Misshapen  corpuscles  (poikilocytes) 
are  very  frequently  observed,  oftener, 
indeed,  than  in  any  other  affection. 
Many  small,  imperfectly  developed 
corpuscles  (microcytes)  are  generally 
found. 

In  marked  cases  corpuscles  endowed 
with  motion  are  occasionally  observed. 
According  to  Hayem,  the  red  blood- 
corpuscles  of  normal  blood  are  motion- 
less. Conversely,  the  elements  observed 
in  cases  of  high  degree  of  anemia  are 
endowed  with  four  kinds  of  motion :  1. 
A  movement  of  the  entire  mass  of  the 
corpuscle.  2.  The  projection  of  mo- 
bile prolongations.  3.  A  movement  of 
oscillation,  manifested  slowly  by  minute 
corpuscles.  4.  A  movement  which  re- 
sults in  changing  the  position  of  the 
corpuscles.  These  movable  corpuscles 
are  bodies  arrested  in  their  evolution 
and  still  retaining  the  contractile  prop- 
erties of  the  hematoblasts  from  which " 
the  red  corpuscles  originate.  On  super- 
ficial examination  they  might  readily 
be  mistaken  for  parasites. 

Many  years  ago  I  observed  distinct 
movements  in  the  red  corpuscles  in  a 
case  of  pernicious  anemia,  but  made 
no  public  mention  of  the  interesting 
fact.  Senator  has  also  called  attention 
to  the  presence  of  small,  mobile  bodies 
observed  staining  the  same  as  red  cor- 
puscles   and    resembling   fragments   of 


630 


ANEMIA,    PERNICIOUS   PROGRESSIVE    (HENRY). 


hematin,  thought  to  possess  pathogno- 
monic value. 

Pernicious  anemia  is  essentially  a 
hemolytic  disease,  the  hemolysis  being 
due  to  some  as  yet  unknown  poison 
comparable  in  its  effect  on  the  blood 
and  blood-organs  to  the  action  of 
toluylenediamine — whether  autointoxi- 
cation or  infection  remains  yet  to  be 
determined.  The  poison  of  pernicious 
anemia  stimulates  the  phagocytes  of 
the  spleen,  lymph-  and  hemolymph- 
glands,  and  bone-marrow  to  increased 
hemolysis  (cellular  hemolysis).  Either 
the  phagocytes  are  directly  stimulated 
to  increased  destruction  of  red  cells  or 
the  latter  are  so  changed  by  the  poison 
that  they  themselves  stimulate  the 
phagocytes.  The  hemolysis  of  perni- 
cious anemia  differs  only  in  degree,  not 
in  kind,  from  normal  hemolysis  or  the 
pathological  increase  occurring  in  sep- 
sis, typhoid,  etc.  It  is  not  improbable 
that  from  the  destruction  of  hemoglo- 
bin poisonous  products  (histon?)  may 
be  formed  which  have  also  a  hemolytic 
action ;  a  vicious  circle  of  hemolysis 
may  thus  be  produced.  No  proof  of 
this  exists  at  present.  The  hemolysis 
of  pernicious  anemia  is  not  confined  to 
the  portal  area,  as  according  to  Hunter, 
but,  in  some  cases  at  least,  takes  place 
also  to  a  large  extent  in  the  prever- 
tebral lymph-  and  hemolymph-  nodes 
and  bone-marrow.  In  the  majority  of 
cases  the  spleen  is  the  chief  seat  of 
the  blood  destruction.  No  evidences  of 
hemolysis  in  the  liver,  stomach,  and 
intestinal  capillaries  were  found  in  the 
8  cases.  The  hemosiderin  of  the  liver 
and  kidneys  is  carried  to  these  organs 
as  some  soluble  derivative  of  hemo- 
globin, is  removed  from  the  circulation 
as  hemosiderin  by  the  endothelium, 
and  then  transferred  to  the  liver- 
or  kidney-  cells.  The  deposit  of 
iron  in  these  organs  is  of  the  nature 
of  an  excretion.  In  the  majority  of 
cases  only  slight  reaction  for  iron  is 
found  at  the  sites  of  actual  hemolysis 
(spleen,  lymph-  and  hemolymph-  glands, 
and  bone-marrow).  The  greater  part  of 
the  pigment  in  the  phagocytes  of  the 
spleen,  lymph-  and  hemolymph-  glands 


does  not  give  an  iron  reaction  while  in 
a  diffuse  form.  When  changed  to  a 
granular  pigment  the  iron  reaction  may 
usually  be  obtained.  The  change  to 
hemosiderin  is  for  the  greater  part  ac- 
complished by  the  endothelium  of  the 
liver  and  kidneys.  The  varying  path- 
ological conditions  found  in  these  dif- 
ferent cases  of  pernicious  anemia  can 
be  explained  only  by  a  theory  of  cyclical 
or  intermittent  process  of  hemolysis. 
This  theory  is  also  borne  out  by  the 
exacerbations  so  frequently  seen  clin- 
ically. The  autopsy  findings,  in  so  far 
as  evidences  of  hemolysis  are  concerned, 
will  depend  on  the  relation  between  the 
time  of  death  and  the  stage  of  the 
hemolysis.  The  changes  in  the  hemo- 
lymph-glands  found  constantly  in  these 
8  cases  were :  dilatation  of  the  blood- 
sinuses  and  evidences  of  increased  he- 
molysis, as  shown  by  the  increased 
number  of  phagocytes  containing  dis- 
integrating red  cells  and  blood-pigment. 
In  some  of  the  cases  these  changes  were 
accompanied  by  great  increase  in  size 
and  apparent  increase  in  the  number  of 
hemolymph-glands ;  in  other  cases  there 
was  no  hyperplasia,  the  only  evidence 
of  the  changes  present  being  that  ob- 
tained by  the  microscopic  examination. 
The  changes  found  cannot  be  regarded 
as  a  specific  of  pernicious  anemia, 
since  it  is  probable  that  they  may  be 
produced  by  other  infections  or  toxic 
processes  characterized  by  great  hemol- 
ysis. The  lymphoid  and  megaloblastic 
changes  in  the  bone-marrow  do  not 
form  an  essential  part  of  the  pathology 
of  pernicious  anemia,  and  are  to  be 
regarded  as  of  a  compensatory  nature : 
an  increased  activity  of  red-cell  forma- 
tion to  supply  the  deficiency  caused  by 
the  excessive  hemolysis.  A.  S.  War- 
thin  (Amer.  Jour.  Med.  Sciences,  Oct., 
1902). 

PATHOLOGY.— In  cases  in  which 
the  urine  is  dark  the  latter  is  found  to 
contain  pathological  urobilin:  a  sub- 
stance known  to  be  derived  from,  the 
disintegration  of  hemoglobin,  and 
which,  according  to  Hunter,  is  of  high 
diagnostic    significance.     A    peculiarity 


ANEMIA,   PERNICIOUS   PROGRESSIVE    (HENRY). 


631 


of  this  highly  colored  urine  is  that  it 
presents  a  low  specific  gravity,  averag- 
ing 1.014.  Occasionally,  however,  the 
urtne  is  habitually  pale.  The  kidneys 
are  often  the  seat  of  fatty  infiltration, 
accompanied  sometimes  by  thickening 
of  the  interstitial  tissue. 

Case  in  which  hemolysis  in  pernicious 
anemia  was  augmented  by  urinary  re- 
tention. The  urinary  retention  was 
secondary  to  relapses  of  the  anemia 
which  caused  weakness  of  the  bladder 
musculature.  Cunningham  (Annals  of 
Surg.,  Feb.,  1907). 

Case  similar  to  Cunningham's,  but  in 
which  an  enlarged  prostate,  which  was 
present  in  both  cases,  was  primarily 
responsible  for  the  urinary  retention. 
Following  this  there  was  a  retention 
and  absorption  of  the  hemolysins  which 
failed  to  be  excreted,  with  consequent 
changes  in  the  course  of  the  disease. 
When  the  poison  that  is  normally  being 
excreted  from  the  kidneys  is  added  to 
that  in  the  general  circulation,  increased 
hemolysis  is  to  be  expected.  H.  A. 
Freund  (Jour.  Amer.  Med.  Assoc,  May 
4,  1907). 

Examination  of  the  kidneys  in  12 
cases  of  pernicious  anemia  of  unknown 
etiology  showed  that  in  every  instance 
fat  was  present  in  the  kidneys,  but  in 
slight  amount  and  in  special  arrange- 
ment in  the  cells,  being  rather  of  the 
nature  of  a  fatty  infiltration  than  a 
'  degeneration  of  the  renal  epithelia.  In 
long-continued  or  very  rapidly  progress- 
ing cases  focal  deposits  of  furruginous 
pigment  were  present,  but  only  in  the 
cortical  substance  in  the  epithelia  of  the 
convoluted  tubules.  In  all  cases  there 
was  a  marked  increase  and  thicken- 
ing of  the  interstitial  tissue  resem- 
bling sclerosis,  most  pronounced  in  the 
medullary  substance.  L.  Paszkiewicz 
(Virchow's  Archiv  f.  Path.  Anat.,  Bd. 
cxcii,  S.  324,  1908). 

Case  illustrates  the  relations  between 
periiicious  anemia  and  renal  lesions. 
A  man  aged  52  years  came  under 
treatment  for  a  grave  anemia,  weak- 
ness, and  generalized  edema.  The  pa- 
tient grew  steadily  worse,  and  died  m 


apparently  uremic  coma.    The  examina- 
tion   of    the    blood    showed    an    intense 
plastic    anemia    with    myeloid    reaction 
and  hyperleucocytosis ;    some   nucleated 
reds  were  present,  and  the  corpuscular 
resistance  was  normal.     At  autopsy  the 
main  lesion  present  was  nephritis  with 
a  kidney  of  the  large  white  type.     The 
factors  of  dilution  of  the  blood,  toxic 
hemolysis,   or   a   defect   in   the   corpus- 
cular   resistance    the    authors    do    not 
think    can    enter    into    this   case.      It    is 
possible,   however,  that  both  the   renal 
and  blood  lesions  are  the  result  of  some 
infection  or  intoxication.     At  any  rate,- 
this   association    of   the   two    lesions   is 
frequent  and  should  be  noted  in  a  con- 
dition  the   cause   of   which   is   so   often 
unknown.     Labbe   and   Joltrain    (Arch, 
des  mal.  du  cceur,  des  vaisseaux,  et  du 
sang,  vol.  i,  p.  366,  1908). 
The  gastric  and  intestinal  disorders 
are  probably  due  to  the  formation  of 
poisons,  which,  we  have  seen,  act,   in 
turn,   as  the   etiological  factors  of  the 
general    disease.     The   gastric   and   in- 
testinal walls  are  often  found  to  be  the 
seat   of    fatty    change,    and   atrophied. 
Carious   teeth  have  been   regarded  as 
potent  factors  in  the  etiology  of  per- 
nicious anemia  by  Hunter,  but  this  view 
has  not  been  sustained.     Intestinal  en- 
tozoa,    hoAvever,    undoubtedly    underlie 
many  cases. 

The  writer  considers  that  the  causa- 
tive process  of  infection  is  double:  (1) 
a  specific  infection  of  which  the  chief 
evidence  is  a  glossitis,  and  (2)  a  septic 
infection  of  the  mouth,  stomach,  and 
intestine  of  which  the  chief  evidences 
during  life  are  varying  degrees  of 
"oral  sepsis"  and  "septic  gastritis,"  the 
latter  recognizable  during  life  by  the 
vomit  and  various  symptoms  of  oral, 
gastric,  and  intestinal  disturbance,  and 
after  death  by  the  conditions  of  gas- 
tritis, gastric  and  intest'nal  atrophy,  and 
now  and  again  erosions  and  ulcers. 
Sepsis  alone  is  incapable  of  giving  rise 
to  true  pernicious  anemia,  for  in  septic 
anemia  there  is  no  evidence  in  the  liver 
of    hemolysis.      A    peculiar    form    of 


632 


ANEMIA,   PERNICIOUS   PROGRESSIVE    (HENRY). 


glossitis  had  been  found  in  every  one 
of  the  25  cases  included  in  the  present 
paper.  There  was  great  thinning  of 
the  mucosa,  which  in  places  was  entirely 
lost,  so  that  the  lymphatics  of  the  tongue 
were  left  in  direct  continuity  with  the 
buccal  cavity.  This  thinning  of  the 
mucosa  produces  the  peculiar  glossy 
surface  of  the  tongue  characteristic  of 
the  disease.  Hunter  (Practitioner,  July, 
1902). 

Repeated  intravenous  injections  of 
living  cultures  of  the  colon  bacillus 
into  rabbits  found  to  cause  the  de- 
velopment of  a  state  of  advanced 
anemia  not  quite  comparable  with  any 
of  the  classical  forms  seen  in  man.  In 
some  respects  it  resembles  pernicious 
anemia,  namely:'  in  the  very  great 
diminution  of  erythrocytes,  the  marked 
poikilocytosis,  and  the  appearance  of 
nucleated  red  corpuscles.  On  the  other 
hand,  it  differs  from  pernicious  anemia 
in  the  fall  of  the  amount  of  hemoglobin 
being  parallel  with  the  decrease  of  the 
red  corpuscles,  in  the  absence  of  a  dis^ 
tinct  and  extensive  Inincke's  siderosis, 
in  the  absence  of  any  clear  evidence  of 
inflammatory  or  other  disturbances  of 
the  digestive  tract,  and  of  well-marked 
changes  in  the  bone-marrow.  In  the 
advanced  stage  of  this  anemia  a  diffuse 
degeneration  of  the  spinal  cord  was  set 
up,  affecting  the  posterior  and  lateral 
columns  of  the  cord,  in  the  lumbar  and 
dorsal  regions.  This  degeneration  con- 
sisted in  a  fatty  degeneration  of  the 
myelin  sheaths  of  the  fibers  and  certain 
pigmentary  changes  in  the  nerve-cell 
bodies  of  the  gray  matter.  The  ventral 
columns  of  the  cord  and  the  gray 
matter  were  not  affected.  Similar  con- 
ditions of  anemia  and  spinal-cord  degen- 
eration could  not  be  produced  by  inject- 
ing killed  cultures  of  the  colon  bacillus, 
nor  by  filtered  cultures.  When  the 
living  cultures  were  acted  upon  by  pep- 
sin, and  injected  intravenously,  they 
did  not  differ  materially  in  their  action 
from  the  original  living  cultures.  G. 
A.  Charlton  (Jour,  of  Med.  Research, 
May,  1904). 

Pernicious  anemia  may  be  due  to  an 
infection  of  the  intestinal  tract  with 
the  Bacillus  aerogenes  capsulatus.     The 


writer  finds  this  organism  regularly  and 
in  large  numbers  in  the  fecal  matter 
of  patients  with  pernicious  anemia, 
whereas  in  ideal  conditions  of  human 
digestion  the  organism  is  present  only 
in  small  numbers.  Reductions  in  the 
number  of  capsulati,  in  these  patients, 
are  followed  by  an  improvement  of 
symptoms.  Neutral  filtrates  from  cul- 
tures of  this  bacillus  in  blood  bouillon 
were  found  to  have  a  marked  hemo- 
lytic power.  Seventeen  cases  of  anemia 
were  studied,  9  imdoubtedly  pernicious, 
4  probably  pernicious,  and  4  possibly 
belonging  to  the  same  class.  Herter 
(Jour,  of  Biol.  Chemistry,  Aug.,  1906). 

The  writer  has  found  no  oral  sepsis 
in  any  of  his  cases,  and  does  not  be- 
lieve this  has  the  influence  in  the  pro- 
duction of  the  disease  which  some 
authorities  have  suggested.  The  glos- 
sitis from  which  many  patients  who  are 
affected  with  pernicious  anemia  suffer 
is  a  consequence  rather  than  a  cause, 
due,  presumably,  to  the  same  toxin, 
whatever  it  may  be,  which  is  the  cause 
of  the  anemia.  Byrom  Bramwell  (Brit. 
Med.  Jour.,  Jan.  22,   1909). 

Tallquist  has  shown  that  Dibothrio- 
cephalus  latus,  which  may  cause  an 
anemia  similar  to  pernicious  anemia, 
contains  a  powerfully  hemolytic  lipoid 
which  can  be  extracted  from  the  body 
of  the  worm,  and  has  been  able  to 
demonstrate  quite  similar  substances  in 
the  mucosa  of  the  human  digestive 
tract.  The  writers  have  pursued  in- 
vestigations of  like  nature,  the  results 
of  which  follow :  1.  In  pernicious 
anemia  there  is  present  in  the  gastric 
and  intestinal  mucosas  a  lipoid  substance 
soluble  in  ether,  which  is  about  ten 
times  as  powerful  a  hemolysin  as  the 
lipoid  obtained  from  the  normal  mucosa 
2.  Tested  experimentally  on  animals, 
this  lipoid  shows  weak,  but  definite 
hemolytic  properties  when  administered 
either  subcutaneously  or  by  the  stom- 
ach. That  obtained  from  the  normal 
mucosa  exerts  much  less  action  or  none 
at  all.  3.  The  resulting  anemia  has 
the  characteristics  of  pernicious  anemia. 
4.  In  dogs  it  is  possible,  to  obtain  a 
lipoid  similar  in  action  to  that  in  per- 
nicious   anemia,    after    first    producing 


ANEMIA,    PERNICIOUS    PROGRESSIVE    (HENRY). 


633 


a  gastrointestinal  catarrh.  5.  The  con- 
clusion seems  justified  that  the  origin 
of  the  so-called  cryptogenic  form  of 
pernicious  anemia  is  to  be  found  in 
the  hemolytic  action  of  this  lipoid  ma- 
terial, with  secondary  insufficiency  of 
the  bone-marrow.  6.  The  place  of 
origin  of  this  powerfully  hemolytic 
lipoid  is  in  all  probability  the  gastro- 
intestinal mucosa ;  the  cause  of  its  pro- 
duction seems  to  be  a  chronic  inflam- 
mation of  the  mucosa.  Berger  and 
Tsuchiga  (Deut.  Archiv  f.  klin.  Med., 
.  xcvi,  S.  252,  1909;  Amer.  Jour.  Med. 
Sci.,  Sept.,  1909). 

Experimental  research  with  the  ex- 
tract of  the  gastrointestinal  mucosa 
after  death  from  pernicious  anemia  and 
with  the  mucosa  from  dogs  with  gas- 
trointestinal affections.  The  extract  of 
the  mucosa  under  certain  conditions 
had  a  pronounced  hemolytic  action.  It 
seems  probable  that  an  inflammatory 
infiltration  in  the  gastrointestinal  mu- 
cosa plays  an-  important  part  in  the 
development  of  pernicious  anemia.  The 
inflammatory  catarrhal  process  leads  to 
the  production  of  an  intensely  hemo- 
lytic lipoid  substance.  That  every 
catarrhal  affection  is  not  accompanied 
by  anemia  is  dvte  to  the  compensating 
action  of  the  bone-marrow  which  re- 
places the  destroyed  blood-corpuscles  as 
fast  as  they  are  destroyed.  The  proc- 
ess has  to  be  very  severe  or  very  long 
continued  to  result  in  a  pernicious 
anemia.  Schmidt  (Deut.  Archiv  f. 
klin.   Med.,   Bd.  xcvi,   Nu.  3-4,   1909). 

The  spleen  is  generally  thought  to 
present  no  characteristic  lesion,  al- 
though the  amount  of  iron  in  it  is  usu- 
ally increased.  It  may,  however,  be 
slightly  enlarged,  and  be  the  seat,  as 
observed  by  Stanley,  of  sclerotic 
changes,  along  with  similar  changes  in 
the  pancreas  and  adrenals. 

In  every  spleen  finely  granular  cells, 
as  myelocytes,  found.  Eosinophilic  my- 
elocytes and  normoblasts  are  only  seen 
in  spleens  which  have  suffered  altera- 
tion through  congestion,  infectious 
processes,  and  severe  anemias.  Under 
certain     conditions     the     spleen     may 


undergo  myeloid  transformation,  partly 
through  the  proliferation  of  the  pre- 
existing myelocytes  and  partly  through 
emigration  to  other  cells,  to  which  class 
belong  the  eosinophiles  and  normo- 
blasts. Kurpjuwcit  (Deutsch.  Archiv 
f.  khn.  Med.,  Bd.  Ixxx,  p.  168,  1904). 

Changes  in  the  spleen  and  liver 
similar  to  those  described  by  Meyer 
and  Bleinecke  in  man  in  pernicious 
anemia  and  in  other  severe  anemias 
may  be  produced  in  animals  by  the 
administration  of  hemolytic  substances ; 
the  writer's  results  confirm  those  ob- 
tained by  Morris.  In  some  instances, 
especially  in  chronic  anemias  with  re- 
generation, the  liver  and  spleen  both 
resembled  the  organs  of  the  embryo  at 
the  stage  when  these  organs  are  en- 
gaged in  hematopoiesis.  Domarns 
(Archiv  f.  exper.  Path.  u.  Pharm.,  Bd. 
Iviii,   S.  319,  1908). 

Jaundice  is  probably  due  to  accumu- 
lation of  iron  in  the  hepatic  system.  In 
a  case  studied  by  Ruttan  and  Adami, 
the  total  quantity  of  iron  found  in  the 
liver  was  '0.2433  per  cent,  by  weight 
calculated  to  the  fresh  undried  tissue. 
This  is  equivalent  to  about  0.72  per 
cent,  to  the  dried  tissue.  The  estima- 
tion accords  fully  with  the  observations 
of  previous  observers,  as  showing  the 
very  great  increase  in  the  iron  con- 
tained in  the  liver  in  this  disease.  Kely- 
nack  and  Coutts  found  it  to  be  five 
times  greater  than  normal.  The  iron  is 
mainly  deposited  about  the  periphery 
and  middle  zone  of  the  lobules,  and  is 
derived  from  the  vast  number  of  de- 
stroyed red  corpuscles.  The  kidneys, 
spleen,  pancreas,  hemolymph-glands  are 
also  laden  with  iron-pigment  derived 
from  these  cells. 

Inquiry  into  the  after-history  of  22 
cases.  The  disease  believed  to  be  due 
to  an  increase  in  the  destructive  action 
of  the  liver  upon  the  red  blood-corpus- 
cles. While  the  22  cases  were  thought 
to  be  "cured"  by  various  means,  10  died 
of  the  disease,  and  only  2  were  known 


634 


ANEMIA,    PERNICIOUS    PROGRESSIVE    (HENRY). 


to  be  living  at  the  time  of  the  investiga- 
tion. H.  C.  Colman  (Edinburgh  Med. 
Jour.,  March  and  April,  1901). 

Case  of  jaundice  associated  with 
weakness  in  which  there  were  no  ab- 
dominal symptoms  or  evidence  of 
obstructive  lesion  of  the  bile-ducts. 
The  blood-picture  was  typical  of 
Addison's  anemia.  There  was  marked 
improvement  of  health  and  disap- 
pearance of  jaundice  under  arsenic 
and  appropriate  hygienic  measures. 
Vanderhoof  (Old  Dominion  Jour,  of 
Med.   and   Surg.,.  April,  1911). 

The  posterior  and  lateral  spinal 
tracts  present  changes  resembling  those 
observed  in  tabes,  but  most  marked  in 
the  posterior  lateral  columns,  as  observed 
by  Nonne,  and  to  a  less  degree  in 
the  lateral  columns.  All  these  changes 
are  not  typical  of  pernicious  anemia, 
however,  and  may  be  met  with  in 
other  diseases  in  which  cachexia  and 
marasmus  predominate,  such  as  Addi- 
son's disease  and  diabetes.  Hemor- 
rhagic areas  in  the  cord  and  brain  due 
to  hyaline  degeneration  of  the  blood- 
vessels are  also  met  with.  We  have 
seen  that  retinal  hemorrhages  consti- 
tute a  diagnostic  feature  of  the  disease. 

Study  of  pathological  lesions  found 
in  the  spinal  cord  in  cases  of  pernicious 
anemia  showed  that  there  was  usually 
a  degeneration  affecting  the  posterior 
columns,  sometimes  the  posterior  and 
lateral  together,  but  never  the  lateral 
alone.  This  degeneration  was  chiefly  in 
the  nerve-fibers,  and  was  unaccom- 
panied by  shrinking  of  the  cord,  such 
as  was  seen  in  locomotor  ataxia. 
Seventeen  cases  analyzed  in  which  in- 
itial nervous  symptom  was  always  a 
persistent  paresthesia,  usually  of  the 
foot,  associated  with  some  weakness. 
This  was  generally  followed  quickly 
by  ataxia  and  loss  of  motor  power,  and 
severe  pains  in  the  back  and  limbs  were 
not  uncommon.  The  disease  progressed 
rather  rapidly,  so  that  often  within  one 
or  two  months  the  symptoms  were  well 
developed.     In    from   six  months  to   a 


year  the  progress  commonly  reached  its 
acme,  and  during  this  time  the  anemia 
became  marked.  After  a  time  the  con- 
trol of  the  bladder  and  the  rectum  was 
lost,  and  in  fatal  cases  death  occurred 
in  from  six  months  to  two  years.  The 
essential  nature  of  the  process  was  a 
primary  nerve  degeneration  affecting 
the  neuraxons  first,  particularly  in  the 
columns  of  Goll  and  the  crossed  py- 
ramidal tract.  The  same  poison  which 
caused  pernicious  anemia  was  respon- 
sible for  this  disease.  It  usually  de- 
veloped between  the  ages  of  50  and  60 
years,  and  followed  the  acute  infec- 
tions, prolonged  diarrheal  or  dysenteric 
attacks,  lead  poisoning,  malarial  infec- 
tion, etc.  In  10  per  cent,  or  more  of 
the  cases  pernicious  anemia  undoubtedly 
coexisted.  Charles  L.  Dana  (N.  Y. 
Med.  Jour.,   Nov.  19,  1898). 

Examination  of  the  spinal  cord  in 
cases  of  pernicious  anemia  by  the 
Marchi  method.  Results  summarized  as 
follows:  (1)  the  changes  in  the  spinal 
cord  in  fatal  cases  of  anemia  are  not 
systematic,  but  should  be  regarded  as 
acute  disseminated  myelitis;  (2)  the 
foci  exhibit  a  local  association  with  the 
blood-vessels;  (3)  it  is  probable  that  a 
noxious  material  is  carried  to  the  cord 
by  the  blood-vessels,  and  this  acts  upon 
the  nervous  tissue ;  similar  changes  are 
found  in  old  age ;  (4)  even  in  advanced 
cases  the  gray  matter  may  escape  in- 
volvement; (5)  if  diseased,  it  is  not  pri- 
marily affected, — that  is  to  say,  it  and 
the  white  matter  are  involved  as  the  re- 
sult of  a  single  cause ;  (6)  the  diffuse 
character  of  the  degeneration  in  these 
conditions  justifies  the  conclusion  that 
there  is  a  trophic  alteration,  and  not  a 
functional  injury  of  the  nervous  ele- 
ment; (7)  the  greater  part  of  degen- 
erated fibers  are  found  in  the  posterior 
roots  and  the  anterior  commissure. 
Nonne  (Deut.  Zeit.  f.  Nervenheilk., 
March  9,  1899). 

There  is  a  well-established  relation 
of  diffuse  cord  degeneration  with  per- 
nicious anemia.  It  seems  highly  prob- 
able that  the  hemolysis  and  the  cord 
changes  are  due  to  the  same  toxin. 
While  the  source  of  the  toxin  is  un- 
known,   the    fact    that    gastrointestinal 


ANEMIA,    PERNICIOUS    PROGRESSIVE    (HENRY). 


635 


disturbance  is  so  common  in  the  disease 
would  lead  one  to  suppose  that  it  is 
of  intestinal  origin.  The  diffuse  de- 
generations of  the  spinal  cord  which 
occur  in  conditions  without  pernicious 
anemia  do  not  appear  to  differ  essen- 
tially from  those  of  pernicious  anemia. 
It  is  possible  that  a  common  blood- 
circulating  poison  exists,  which  may 
expend  its  force  upon  the  blood  in  one 
individual,  upon  the  nervous  apparatus 
in  another,  and  coincidently  upon  the 
blood  and  spinal  cord  in  others.  Frank 
Billings  (Boston  Med.  and  Surg.  Jour., 
Aug.  28  and  Sept.  4,   1902). 

Case  which  shows  the  alterations  in 
the  sympathetic  nervous  system  in  per- 
nicious anemia.  The  celiac  and  superior 
cervical  sympathetic  ganglia  were  ex- 
amined microscopically  after  having 
been  stained  by  Nissl's  method.  The 
nerve-cells  were  found  profoundly  al- 
tered; in  fact,  in  most  of  them  the 
nucleus  was  either  no  longer  visible 
or  cloudy,  deformed,  and  displaced 
toward  the  periphery  of  the  cell.  In 
many  cells  there  was  a  granular  pig- 
ment scattered  through  the  protoplasm 
in  the  form  of  yellowish-brown  refrac- 
tile  granules.  In  other  places  the 
protoplasm  was  found  in  a  condition 
of  fatty  degeneration.  In  places  the 
cell  body  was  but  very  faintly  visible, 
and  the  nerve-processes  indistinct,  at- 
rophied, and  in  some  cases  fatty.  G. 
Vincenzo  (Gaz.  degli  osped.  e  delle 
clin.,  Sept.  23,  1900). 

Out  of  50  cases  of  pernicious  anemia, 
about  20  showed  nervous  manifestations 
of  one  kind  or  another.  The  writer 
analyzed  the  cases  with  the  view  of 
classifying  the  nervous  symptoms,  but 
without  determining  any  definite  groups. 
At  one  end  of  the  series  are  merely 
sensory  disturbances,  and  at  the  other 
complete  paraplegia  with  loss  of  control 
of  bladder  and  rectum.  Report  of  3 
cases  as  examples  of  different  types. 
McCrae  (Bull.  Johns  Hopkins  Hosp., 
Feb.-March,  1902). 

Two  cases  illustrating  2  of  the  types 
of  nervous-system  involvement.  In  the 
first  case,  which  had  the  longest  and 
more    pronounced    history    of    anemia, 


the  nervous  symptoms  were  at  a  mini- 
mum and  the  posterior  columns  of  the 
cord,  particularly  in  the  cervical  region, 
alone  showed  degeneration,  characteris- 
tically patchy  in  distribution.  In  the 
second  case,  the  nervous  involvement, 
particularly  in  the  later  stages,  over- 
shadowed the  anemia.  Here  the  spinal 
cord  presented  very  extensive,  yet  in- 
complete degeneration  with  slight  re- 
placement gliosis  in  the  posterior  col- 
umns, and  also  a  similarly  irregular, 
but  more  diffuse  degeneration  in  the 
lateral  tracts,  which,  however,  was  a 
rather  less  complete  and  apparently 
somewhat  more  recent  process.  Camac 
Milne  (Amer.  Jour.  Med.  Sci.,  Oct., 
1910). 

The  bone-marrow  usually  presents 
changes  which  indicate  abnormal  activ- 
ity, being  composed  mainly,  when  the 
case  is  not  too  far  advanced,  of  hemat- 
oblasts,  as  emphasized  by  Rindfleisch. 
It  resembles  in  this  state,  as  noted  by 
H.  C.  Wood,  Pineau,  and  others,  the 
hemoblastiQ  marrow  of  childhood. 
Other  changes  frequently  found,  ac- 
cording to  Muir,  are  (a)  increased 
number  of  nucleated  red  corpuscles  in 
the  marrow;  (b)  transformation  of  the 
fatty  marrow  in  the  shafts  of  the  long 
bones  into  red  marrow;  (c)  absorption 
of  the  bone  trabeculse  between  the  red 
marrow.  Later,  it  presents  all  the 
signs  of  excessive  compensative  func- 
tion, being  actually  hypertrophied  in 
some  instances.  When  this  stage  is 
reached  the  bone-marrow  may  lose  its 
power  to  create  red  corpuscles. 

The  proteids  of  the  plasma  may  be 
altered  in  their  respective  proportions, 
and  considerably  reduced — 40  per  cent, 
below  the  average  normal  quantity,  ac- 
cording to  Ruttan  and  Adami — the 
globulins  being  especially  reduced. 

As  ill  understood  as  the  etiology  of 
the  disease  is  the  actual  condition  of  the 
blood.  The  microscopic  appearances 
are  well  known,  but  the  true  chemical 


636 


ANEMIA,    PERNICIOUS    PROGRESSIVE    (HENRY). 


changes  have  ahuost  entirely  been  neg- 
lected.    The  blood  in  pernicious  anemia 
contains  a  larger  quantity  of  water  than 
normal    blood,    a    smaller    quantity    of 
solids,  a  higher  proportion  of  chlorine, 
and   a   lower   proportion   of   potassium, 
iron,  and  fat.    There  is  not  sufficient  so- 
dium to  hold  the  chlorine  fixed,  and  the 
potassium  is  also  deficient.     In  various 
tissues    the    proportion    of    water    was 
higher  than   normal   in   the   heart,   and 
lower   in   the    liver,    spleen,    and   brain. 
Treatment    of    pernicious    anemia    with 
potassium   carbonate,   tartrate,    and   cit- 
rate in  4  cases,  3  of  which  were  dying, 
resulted  in  recovery.    Th.  Rumpf  (Berl, 
klin.  Woch.,  May  6,  1901). 
Although  fatty  degeneration  is  pres- 
ent in  practically  all  organs,  emaciation 
is  exceptional,  though  the  adipose  tis- 
sue is  pale  and  yellowish,  contrasting 
with   the  usually  red  muscular   tissue. 
The   heart,    however,    is    enlarged   and 
flabby,   and  its  muscular  elements  are 
pale,    friable,    and    fatty,    its    cavities 
containing    light-colored    blood.      The 
general     fatty     degeneration     affecting 
markedly   the    vessel    walls,    these    are 
extremely    friable;    hence,    the   hemor- 
rhages, retinal,  cutaneous,  etc.,  and  the 
ecchymoses  so  frequently  witnessed. 

DIAGNOSIS.— While  pernicious 
anemia  possesses  characteristics  that 
readily  distinguish  it  from  other  blood 
affections, — the  color  of  the  skin,  the 
retinal  hemorrhages,  etc., — the  early 
stages  are  generally  such  as  to  suggest 
diseases  that  do  not  present  the  same 
degree  of  danger. 

Benign  Anemia. — Intractability  of 
the  disease,  after  the  removal  of  sup- 
posed causes  and  the  faithful  use  of 
appropriate  measures  of  treatment, 
strongly  suggests  the  presence  of  per- 
nicious anemia. 

Chlorosis. — From  this  affection  per- 
nicious anemia  may  readily  be  dif- 
ferentiated by  the  blood  examination. 
Instead  of  relative  increase  of  hemo- 


globin, the  presence  of  gigantoblasts, 
marked  oligocythemia,  and  macrocytes 
differentiate.  The  red  corpuscles,  in 
chlorosis,  may  be  normal  in  number  and 
size,  the  only  change  being  a  deficiency 
of  hemoglobin.  Again,  the  corpuscles 
may  be  normal  in  number,  but  dimin- 
ished in  size,  while  the  percentage  of 
hemoglobin  is  normal ;  finally,  the  cor- 
puscles may  be  diminished  in  number 
with  either  a  diminished,  normal,  or 
perhaps  an  increased  percentage  of 
hemoglobin. 

The  important  diagnostic  points  ob- 
served in  20  cases  were:  (1)  the  high 
color  index;  (2)  the  severe  degree  of 
poikilocytosis ;  (3)  the  constant  pres- 
ence of  polychromatophilia ;  (4)  the 
number  of  megaloblasts,  usually  pre- 
dominating over  the  normoblasts.  The 
writer  considers  these  points  to  be 
pathognomonic  of  the  disease.  Billings 
(Amer.  Jour.  Med.  Sci.,  Nov.,  1900). 

Of  all  the  morbid  changes  which  oc- 
cur in  the  blood,  the  most  important 
is  the  presence  of  megaloblasts.  In 
29  cases  of  the  malady  observed  by  the 
author,  only  in  1  could  these  large 
corpuscles  not  be  found  on  repeated 
examination ;  in  the  remaining  28  they 
were  present,  and  in  the  majority  of 
instances  could  be  detected  on  the  first 
examination.  Naegeli  (Wiener  med. 
Woch.,  Aug.  22,  1903). 

Leucocythemia. — This  disease  may 
be  excluded  by  the  absence  of  the 
characteristic  blood-change:  excess  of 
white  corpuscles. 

Pseudoleucocythemia  is  excluded 
by  the  absence  of  the  affection  of  the 
lymphatic  glands  which  characterizes 
this  disease,  more  commonly  known  as 
Hodgkin's  disease. 

Leukemia. — In  leukemia  the  patient 
often  does  not  show  enough  pallor  to 
make  the  physician  suspect  the  disease. 
The  lips  have  a  dirty-red  color  rather 
than  a  peculiar  pallor.  The  number  of 
white  corpuscles  would  cause  pallor  in 


ANEMIA,    PERNICIOUS    PROGRESSIVE    (HENRY). 


637 


a  patient  with  simple  anemia,  but  in 
this  disease  the  opacity  of  the  l)loo(l  is 
great  and  the  pallor  fails  to  show 
(Jane  way). 

Gastric  Cancer. — This  condition  al- 
most always  shows  itself  after  the  age 
of  40  years,  whereas  pernicious  anemia 
is  generally  observed  early  in  life.  In 
cancer  the  skin  is  pale;  in  pernicious 
anemia  the  peculiar  lemon  color  is 
striking  in  the  majority  of  cases.  While 
gastric  symptoms  and  absence  of  hy- 
drochloric acid  are  prominent  features 
of  cancer,  the  digestive  disorder  is 
slighdy  marked  in  anemia  and  exam- 
ination of  the  gastric  contents  is  nega- 
tive. 

The  reduction  of  red  cells  is  greater 
in  pernicious  anemia  than  in  cancer. 
The  reduction  of  hemoglobin  relative 
to  corpuscles  is  not  so  great  in  per- 
nicious anemia  as  in  cancer.  The  aver- 
age size  of  red  cells  is  greater  and 
polychromatophilia  is  marked  in  per- 
nicious anemia.  In  cancer  the  cells  are 
small  and  may  show  fissures,  but  not  so 
marked  polychromatophilia.  Megalo- 
blas!s  are  present  generally  in  greater 
numbers  than  normoblasts  in  pernicious 
anemia;  their  mere  presence  is  of  great 
importance,  as,  although  normoblasts 
are  common,  megaloblasts  occur  with 
very  great  rarity  in  cancer.  In  the 
absence  of  complication  there  is  fio 
leucocytosis,  and  in  the  absence  of 
fever  there  is  lymphocytosis  in  perni- 
cious anemia.  In  cancer  leucocytosis  is 
the  rule;  lymphocytosis  does  not  occur. 
The  author  refers  to  four  groups  of 
cases,  and  in  each  group  the  blood 
characteristics  have  something  in  com- 
mon :  acute  favorable  cases ;  chronic 
cases;  subacute  cases;  acute  unfavorable 
cases.  Alexander  Goodall  (Scottish 
Med.  and  Surg.  Jour.,  April,   1902). 

The  value  of  laboratory  methods  in 
the  dififerential  diagnosis  of  pernicious 
anemia  and  cancer  of  the  stomach  is 
illustrated  by  the  case  of  a  man  50 
years  of  age  who  had  been  regarded  as 
a  case  of  gastric  cancer  by  other  physi- 
cians until  his  blood  had  been  carefully 


examined.  In  such  cases  when  megalo- 
blasts are  found  in  the  blood  we  have 
a  positive  diagnosis  of  pernicious 
anemia,  while  if  there  is  cancer  of  the 
stomach  the  principal  feature  of  the 
blood  is  a  marked  leucocytosis.  Cer- 
coni   (Riforma  medica,  July  6,  1907). 

Finally,  increasing  emaciation  at- 
tends a  cancerous  disorder,  whereas  in 
cases  of  pernicious  anemia  the  patient 
not  only  retains  his  adipose  tissues,  but 
sometimes  becomes  corpulent.  In  rare 
cases,  however,  there  has  been  extreme 
emaciation. 

Is  it  possible  to  diagnose  pernicious 
anemia  by  the  early  symptoms  before 
the  appearance  of  the  characteristic 
blood-picture  of  the  disease?  While 
the  literature  shows  that  there  is  no 
regularity  in  the  order  of  their  appear- 
ance, there  are  facts  enough  to  indicate 
their  importance.  In  the  writer's  20 
cases,  achylia  gastrica,  with  its  asso- 
ciated diarrhea,  was  present  in  14,  and 
in  9  it  was  a  very  early  symptom.  In 
one  case  it  seemed  to  have  been  present 
thirty-five  years  before  the  blood  con- 
dition was  recognized,  and  in  another 
it  was  present  eight  years  before  the 
blood-picture  developed ;  i  i  still  another 
case  reported  it  was  present  six  years 
before. 

The  nervous  phenomena  may  occur 
early  or  late,  and  in  only  1  of  his  6 
cases  with  early  nervous  symptoms  did 
they  appear  before  the  signs  in  the 
blood  were  found.  The  cardiovascu- 
lar are  the  least  characteristic  early 
symptoms;  in  only  1  of  his  5  cases 
presenting  them  as  such  did  he  prop- 
erly interpret  them  before  finding  the 
pathognomonic  blood  signs."  The  au- 
thor, therefore,  is  unable  at  present  to 
describe  a  symptom-complex  indicating 
pernicious  anemia  before  the  occur- 
rence, or  discovery,  of  the  blood 
changes,  but  he  believes,  nevertheless, 
that  a  more  careful  study  of  patients 
in  the  early  stages  of  the  disease  will 
give  considerable  evidence  that  such  a 
symptom-complex  exists.  J.  A.  Lichty 
(Jour.  Amer.  Med.  Assoc,  June  29, 
1907). 


638 


ANEMIA,    PERNICIOUS    PROGRESSIVE    (HENRY). 


The  pernicious  anemia  of  infants — 
a  rare  condition — is  recognized,  ac- 
cording to  Rotch  and  Ladd,  through 
the  following  diagnostic  points:  The 
insidious  onset  with  moderate  and  par- 
oxysmal attacks  of  indigestion,  the 
extreme  pallor,  great  loss  of  strength, 
slightly  elevated  temperature  for 
months,  and  absence  of  glandular  or 
splenic  enlargement  or  of  any  demon- 
strable cause  for  a  secondary  anemia. 
The  signs  which  are  almost  pathogno- 
monic in  adults  lose  significance,  on 
account  of  the  greater  instability  of  the 
infant's  blood-making  function.  Mega- 
loblasts,  normoblasts,  macrocytes,  and 
poikilocytes  may  occur  in  grave  anemia 
as  other  than  "pernicious";  still,  these 
elements  are  needed  for  diagnosis. 

ETIOLOGY.  — The  main  patho- 
genic factor,  hemolysis,  has  been  re- 
viewed under  a  preceding  heading;  we 
still  have  to  consider,  however,  the  con- 
ditions which  either  predispose  to  the 
disease  or  are  capable  of  causing  it. 

As  to  predisposing  agencies,  although 
the  disease  occasionally  occurs  in  chil- 
dren, it  is  most  common  in  adults  be- 
tween the  ages  of  20  and  40  years. 
Males  are  attacked  more  frequently 
than  females,  with  a  slight  difference  in 
favor  of  the  former.  The  disease  is 
more  prevalent  among  the  better  than 
in  the  lower  classes,  and  is  miost  com- 
mon in  Europe,  especially  in  Switzer- 
land, e.g.,  in  regions  in  which  the  peo- 
ple are  badly  fed  and  hve  in  poorly 
ventilated  and  badly  lighted  houses. 
F>ight  and  grief  are  prominent  etiolog- 
ical factors.  Syphilis,  sarcoma,  and 
other  disorders  capable  of  impairing 
hematopoietic  functions  of  the  bones 
are  also  capable  of  bringing  on  the 
disease. 

According  to  Grawitz,  the  following 
group  of   etiological   factors  has  been 


established :  1.  Gastrointestinal  disease 
of  long  standing,  poor  food,  impaired 
digestion;  chronic  constipation,  espe- 
cially in  women  frequently  pregnant; 
irregular  defecation  in  women  and 
girls,  especially  those  of  hysterical 
temperament.  In  such  cases  it  is  due 
to  intoxication  from  the  gastrointes- 
tinal tract.  2.  Pregnancy.  Here,  too, 
probably,  there  is  an  autointoxication 
from  the  intestinal  tract,  on  account  of 
pressure  exerted  by  the  gravid  uterus 
on  the  bowel.  3.  Chronic  hemorrhages, 
especially  of  small  size.  4.  Constitu- 
tional syphilis,  particularly  when  asso- 
ciated with  sclerosis  of  the  marrow  of 
the  long  bones.  5.  Bad  hygienic  con- 
ditions of  various  kinds,  especially  in 
the  female  sex ;  hard  work,  with  insuf- 
ficient food,  bad  air,  and  emotional 
excitement.  In  higher  social  strata  the 
disease  may  be  found  in  women  who 
are  subjected  to  intense  mental  strain 
as  the  result  of  a  desire  to  equal  men 
in  physical  efforts.  Frequent  preg- 
nancy and  prolonged  lactation  are  also 
factors.  6.  Chronic  poisoning,  as,  e.g., 
by  carbon  monoxide.  7.  Bothriocephalus 
and  ankylostomum — those  cases  belong 
here  that  are  not  cured  after  the  expul- 
sion of  the  worms. 

Variations  in  nitrogenous  metabolism 
of  21  cases  of  bothriocephalus  anemia 
studied  at  the  Helsingfors  medical 
clinic.  In  all  cases  there  was  a  distinct 
nitrogen  loss  up  to  8.8  grams  per  day 
before  the  worm  was  expelled.  After- 
ward the  nitrogenous  balance  was  at 
once  or  by  degrees  entirely  regained. 
In  some  cases  there  was  retention  of 
nitrogen.  The  writer  ascribes  the  in- 
creased nitrogen  output  to  the  action 
of  a  toxin  produced  by  the  worm  upon 
albuminous  matter.  No  parallel  was 
found  between  the  blood  conditions  and 
the  nitrogenous  excretion.  With  a 
purin-free  diet  the  urinary  purin  excre- 
tion showed  marked  variations.  Dur- 
ing  the   toxic   period — that   is   to   say, 


ANEMIA,    PERNICIOUS    PROGRESSIVE    (HENRY). 


639 


while  the  worm  was  present  in  the  in- 
testines— the  endogenous  purin  excre- 
tion was  very  large.  When  the  worm 
has  been  removed,  the  quantity  of  purin 
excreted  sank  rapidly  to  the  normal. 
In  some  cases,  however,  it  continued 
high  for  some  days  after  the  expulsion 
of  the  worm.  The  toxins  secreted  by 
the  worm  evidently  incite  leucocytosis 
to  a  high  degree,  and  also  extensive 
destruction  of  nuclear  matter.  E. 
Rosengrist  (Zeit.  f.  klin.  Med.,  Bd. 
xlix,  1903). 

Pernicious  anemia  is  not  a  specific 
entity,  but  a  clinical  syndrome  of  var}'- 
ing  etiology.  Etiologically,  the  disease 
can  be  considered  as  cryptogenetic,  or 
of  concealed  origin.  Under  the  former 
the  writers  group :  (1)  repeated  hemor- 
rhage (gastric,  uterine,  nasal,  and  ves- 
ical) ;  (2)  intestinal  parasites  (bothrio- 
cephalus  and  ankylostoma)  ;  (3)  ma- 
laria; (4)  bacterial  infections;  (5) 
tuberculosis;  (6)  syphilis;  (7)  cancer, 
especially  gastric ;  (8)  gastrointestinal 
disorders  and  autointoxications,  which 
are  said  to  be  the  cause  of  the  so-called 
idiopathic  cases;  (9)  nephritis;  (10) 
pregnancy;  (11)  lead;  (12)  carbon 
monoxide,  arsenic,  and  opium.  The 
factors  necessary  for  any  of  the  above 
conditions  to  result  in  this  syndrome 
are  (a)  an  excessive  intensity  of  the 
morbid  cause;  (b)  the  localization  of 
the  infection ;  (c)  the  duration  or 
rep.etition  of  the  cause;  (d)  an  accumu- 
lation of  the  morbid  condition ;  (e) 
predisposition.  On  the  whole,  pro- 
gressive pernicious  anemia  can  be  the 
final  stage  of  secondary  anemias.  Ladd 
and  Salomon  (Revue  de  med.,  April 
and  May,   1908). 

Three  cases  of  severe  anemia  wit- 
nessed due  to  repeated  small  bleed- 
ings and  occasionally  larger  ones 
from  varicosities  situated  10  to  15  cm. 
above  the  anus  which  could  easily  be 
seen  with  the  proctoscope.  Destruc- 
tion of  these  varicosities  by  the 
Paquelin  cautery  rapidly  cured  the 
anemia.  C.  A.  Ewald  (Berl.  klin. 
Woch.,  Jan.  9,  1911). 

Pregnant  women  represent  the  larg- 
est proportion  of  cases.     Repeated  par- 


turition is  probably  the  most  prolific 
cause  of  the  disease,  for  it  is  seldom 
met  with  in  primiparre.  Excessive  and 
prolonged  lactation  and  puerperal  hem- 
orrhages and  other  exhausting-  condi- 
tions frequently  appear  as  the  primary 
element  in  the  causation  of  the  disease. 

Certain    atrophic    conditions  .of    the, 
gastric    mucous    membrane,    ulcers    of 
the  stomach,  malaria,   syphilis,  cancer, 
•  and  alcoholism  have  also  been  consid- 
ered as  etiological  factors. 

PROGNOSIS.— Although  the  dis- 
ease terminates  fatally  when  left  to 
itself,  the  mortality  from  very  nearly 
100  per  cent,  has  been  reduced  since 
the  introduction  of  arsenic.  A  guarded 
prognosis  should  always  be  given,  how- 
ever, relapses  being  exceedingly  com- 
mon. About  one-half  of  the  fatal  cases 
last  from  one  to  six  months ;  the  re- 
maining seldom  reach  beyond  the  sec- 
ond year.  Periods  of  transitory  im- 
provement of  varying  duration  are 
often  a  part  of  the  natural  course  of 
the  disease;  so  that  too  much  impor- 
tance must  not  be  attached  to  the  favor- 
able results  that  may  follow  the  special 
line  of  medication  employed.  Even  if 
such  improvement  continues  for  a  long 
time,  the  conclusion  must  not  be  too 
hastily  reached  that  the  disease  is 
cured.  According  to  Goodall,  the  prog- 
nosis may  to  a  certain  extent  be  based 
upon  certain  characteristics  of  the 
course  of  the  blood-picture : — 

1.  Acute  Favorable  Cases. — In  these 
the  symptoms  are  marked;  the  red  cells 
are  much  diminished,  but  show  a  tend- 
ency to  rise ;  the  megaloblasts  are  atyp- 
ical and  not  numerous ;  the  normoblasts 
are  numerous ;  the  color  index  is  high, 
but  tends  to  fall ;  the  polychromato- 
philia  is  not  marked;  the  percentage  of 
polymorphonuclear  cells  is  high ;  the 
myelocytes  are  absent  or  scanty. 


640 


ANEMIA,    PERNICIOUS   PROGRESSIVE    (HENRY). 


Course. — A  remission  to  a  fairly 
normal  condition  may  occur,  which 
may  be  maintained  for  years. 

2.  Chronic  Cases. — In  these  the 
symptoms  are  not  well  marked ;  the  red 
cells  tend  to  remain  about  one  or  two 
million;  the  megaloblasts  are  absent  or 
scanty;  the  normoblasts  are  absent  or 
scanty ;  the  color  index  is  generally 
low;  the  polychromatophilia  is  slight; 
the  percentage  of  lymphocytes  is  high; 
the  myelocytes  are  scanty. 

Course. — The  cases  are  apt  to  be 
chronic.  The  patients  can  work, 
though  they  feel  weak,  and,  though 
febrile  attacks,  etc.,  may  occur,  they 
have  little  bad  effect.  The  improve- 
ment seldom  occurs,  but  the  duration 
may  be  for  several  years. 

3.  Subacute  Cases. — In  these  the 
symptoms  are  fairly  well  marked ;  the 
red  cells  about  one  million,  showing 
slow  and  irregular  tendency  to  rise ;  the 
megaloblasts  are  numerous ;  the  normo- 
blasts are  less  numerous  than  megalo- 
blasts; the  color  index  is  high;  the 
polychromatophilia  is  distinct;  the  per- 
centage of  lymphocytes  is  high  in  the 
absence  of  fever;  the  myelocytes  are 
fairly  numerous. 

Course. — Symptoms  improve;  blood 
improves  to  a  certain  extent.  The 
duration  is  about  two  years,  unless  com- 
plications reduce  this  period. 

4.  Acute  Unfavorable  Cases. — In 
this  type  the  symptoms  are  marked, 
and  there  may  be  hemorrhages ;  the  red 
cells  are  about  one  million,  and  tend  to 
remain  or  go  lower;  the  megaloblasts 
are  typical  and  numerous ;  the  normo- 
blasts are  less  numerous  than  megalo- 
blasts ;  the  color  index  is  high ;  the 
polychromatophilia  is  marked ;  the  per- 
centage of  lymphocytes  is  high  in  the 
absence  of  fever;  the  myelocytes  may 
be  numerous. 


Course. — A  fatal  termination  is  to  be 
expected  in  a  few  months. 

With  improvement  of  blood  condi- 
tions improvement  of  the  general  health 
by  no  means  always  follows.  Patients 
with  pernicious  anemia  do  not  always 
die  of  the  anemia  itself,  for  many  cases 
with  abnormally  low  hemoglobin  and 
blood-count  improve.  They  die  more 
frequently  of  the  secondary  organic 
changes  caused  by  the  anemia,  chief 
among  which  are  fatty  degeneration 
of  the  heart  muscle  and  functional  dis- 
orders of  the  nervous  system.  The 
prognosis  is,  therefore,  not  alone  de- 
pendent upon  the  blood  conditions,  but 
also  upon  that  of  the  other  organs. 
Conclusions  from  the  blood  alone  can 
lead  to  great  error  in  the  prognosis. 
Hirschfeld  (Therapie  der  Gegenwart, 
Nu.  8,  1907). 

The  tendency  to  relapse  is  in  reality 
due  to  the  remarkable  persistence  of 
the  specific  hemolytic  infection  under- 
lying the  disease,  since  it  is  always  ac- 
companied by  a  recrudescence  of  the 
lesions  in  the  tongue,  stomach,  or  in- 
testine, and  by  the  glossitic,  gastric,  or 
intestinal  symptoms  connected  there- 
with. Hunter  (Brit.  Med.  Jour.,  Nov. 
9,  1907). 

The  immediate  prognosis  in  certain 
cases  of  pernicious  anemia  with  blood 
depletion  below  400,000,  although  seri- 
ous, is  not  hopeless.  The  prognosis  de- 
pends on  the  degree  of  red-cell  regen- 
eration in  the  bone-marrow,  the  age  of 
the  individual  and  the  potency  of  the 
hemolytic  poison  being  important  fac- 
tors. Stone  (Jour.  Amer.  Med.  Assoc, 
April  18,  1908). 

Report  of  3  cases  of  pernicious 
anemia  .with  remissions,  with  tabulated 
blood-counts.  In  one  case  the  improve- 
ment followed  the  removal  of  the  pa- 
tient from  the. county  farm  to  the  hos- 
pital, where  the  better  hygienic  and 
dietary  conditions  were  undoubtedly  a 
strong  factor.  In  several  cases  ob- 
served, out  of  a  total  of  25  in  the  last 
two  and  a  half  years,  in  which  fermen- 
tative changes  in  the  intestines  were 
a  prominent  symptom,  high  colonic  irri- 
gations with  physiological  salt  solution 


ANEMIA,    PERNICIOUS    PROGRESSIVE    (HENRY). 


6+1 


seemed  to  be  connected  with  remissions 
of  improvement.  Though  the  blood- 
count  shows  a  marked  improvement  in 
the  remissions,  there  are  still  abnormal 
features  indicating  that  a  disturbance  in 
hematogenic  function  still  exists.  At 
best  a  remission  is  but  a  partial  cure, 
and  reserve  in  prognosis  and  caution  in 
interpreting  apparent  therapeutic  results 
are  alwaj'S  advisable.  W.  L.  Bierring 
(Jour.  Amer.  Med.  Assoc,  Aug.  1, 
1908). 

Case  of  pernicious  anemia  in  which 
there  was  a  period  of  complete  remis- 
sion of  symptoms,  amounting  to  a  cure 
for  some  sixteen  years,  with  final  re- 
lapse showing  all  the  characteristic 
symptoms  and  pursuing  a  truly  pro- 
gressive course  to  a  fatal  ending.  A. 
McPhedran  (Amer.  Jour.  Med.  Sci., 
Aug.,  1910). 

TREATMENT.— Arsenic  cures  the 
curable  cases  and  benefits  the  others. 
Iron  is  worse  than  useless,  having 
shown  itself  injurious  in  several  cases 
reported — doubtless  because  the  liver 
is  already  overladen  with  iron.  Fowl- 
er's solution  may  be  given  in  3-minim 
doses  three  times  a  day,  increased  by  1 
minim  daily  until  30  minims  are  taken 
after  each  meal,  provided  the  stomach 
does  not  rebel,  which  is  seldom  the 
case.  The  patient  should  be  watched 
and  the  drug  reduced  or  discontinued 
temporarily  on  the  appearance  of  any 
of  the  physiological  effects  of  arsenic: 
edema  of  the  lids,  etc.  In  some  in- 
stances the  doses  have  been  increased 
with  marked  benefit  until  as  much  as 
20  drops  were  taken  at  a  dose. 

According  to  Grawitz,  rest  in  bed  is 
one  of  the  first  requisites ;  the  assimi- 
lation of  food  must  be  stimulated.  The 
patient  should  be  placed  on  a  milk  and 
vegetable  diet.  Lavage  of  the  stom- 
ach, intestinal  irrigation,  and  saline 
laxatives  are  useful.  If  the  urine  con- 
tains much  indican  intestinal  antisep- 
tics are  indicated.     He  also  regards 


arsenic  as  the  best  remedy ;  it  can  be 
given  with  quiiine.  Inhalations  of 
oxygen  have  been  employed  with  ad- 
vantage. Massage  and  gymnastic  ex- 
ercises are  often  of  service.  After 
apparent  recovery  the  patient  must  be 
carefully  observed,  as  relapses  are 
likely  to  occur,  particularly  if  the  hy- 
gienic and  dietetic  conditions  are  un- 
favorable. 

Case  of  pernicious  anemia  treated  by 
Grawitz's  method.  The  patient  was  a 
man  33  years  old  who  was  admitted 
to  the  hospital  after  suffering  for  five 
weeks  from  anemia  and  weakness.  All 
the  symptoms  manifested  by  the  patient 
were  that  of  a  typical  case  of  pernicious 
anemia.  Treatment  consisted  of  a  strict 
diet  of  milk  and  vegetables,  daily  ene- 
mata,  with  arsenic  and  hydrochloric 
acid  given  by  the  mouth.  Lavage  of 
the  stomach  was  not  performed,  owing 
to  the  strenuous  objections  on  the  part 
of  the  patient.  After  eight  weeks  in 
the  hospital  and  a  month's  holiday  in 
the  mountains  his  general  condition 
was  excellent,  and  there  has  been  no 
relapse.  The  adventitious  sounds  which 
had  been  heard  over  the  heart  and 
cervical  veins  had  disappeared.  He  no 
longer  felt  dyspnea  on  slight  exertion, 
the  temperature  became  normal,  and 
the  pulse  was  68-80.  The  blood-count 
showed  4,235,000  red  cells  and  no  ab- 
normal cells,  as  compared  with  1,300,000 
red  cells  and  numerous  microcytes  and 
megalocytes  and  a  marked  poikilocyto- 
sis'  and  polychromatophilia  on  admis- 
sion to  the  hospital.  The  success  ob- 
tained in  this  and  similar  cases  tends 
to  confirm  the  view  that  the  disease  is 
toxemia,  caused  by  a  deficiency  of  hy- 
drochloric acid  in  the  gastric  juice  and 
a  possibly  subsequent  splitting  up  of 
albuminous  molecules  into  toxic  bodies 
rather  than  to  a  primary  disease  of  the 
blood  or  blood-forming  organs.  L. 
Nicolayson   (Lancet,  Nov.  7,  1908). 

Experiments  based  on  the  hemolytic 
action  of  distilled  water  show  that 
arsenious  acid  forms  a  fixed  combina- 
tion with  red  blood-cells  and  acts  as  a 
protective  agent  against  hemolytic  agen- 


1—41 


642 


ANEMIA,    PERNICIOUS    PROGRESSIVE    (HENRY). 


cies.  The  protective  action  of  arsenic 
was  perceptible  when  the  experimental 
solution  was  as  weak  as  1 :  400,0(30. 
The  ordinary  maximum  dose  of  arsenic 
is  0.005  gram,  and  if  this  was  all  ab- 
sorbed the  amount  of  arsenic  in  the 
blood  would  be  1 :  1,000,000.  How- 
ever, arsenic  is  frequently  given  in 
larger  doses  in  the  organic  combina- 
tions, and  it  is  very  slowly  eliminated. 
Furthermore,  arsenic  seems  to  attach 
itself  so  rapidly  and  so  firmly  to  the 
red  blood-cells  that  it  is  probable  that 
the  drug  is  largely  taken  up  by  them. 
Therefore,  the  writer  believes  that 
arsenic  is  of  benefit  in  pernicious 
anemia  because  it  prevents  the  destruc- 
tion of  the  red  blood-cells,  and  that 
arsenic  protects  the  red  blood-cells 
from  invasion  by  the  malarial  parasite, 
but  that  it  does  not  destroy  the  parasite. 
Gunn  (Brit.  Med.  Jour.,  No.  2481,  p. 
145,  1908). 

When  the  gastric  disorder,  which  is 
a  usual  symptom,  prevents  the  admin- 
istration of  arsenic,  the  latter  may  be 
given  subcutaneously,  while  the  stom- 
ach is  treated  directly  by  lavage. 

'An  excess  of  hydrochloric  acid  is  not 
uncommonly  found  in  the  gastric  se- 
cretions. In  such  cases  See  recom- 
mends an  almost  exclusive  diet  of  meat 
and  other  albuminous  foods :  raw 
meat  to  the  extent  of  10  to  12  ounces 
daily.  As  a  rule,  however,  there  is 
deficiency  of  hydrochloric  acid  and 
pepsin,  especially  in  advanced  cases. 
Good  effects  have  been  obtained  from 
large  doses  of  hydrochloric  acid  and 
pepsin  under  these  conditions. 

The  great  majority  of  cases  of  per- 
nicious anemia  suffer  from  an  absence 
of  hydrochloric  acid  and  pepsin  in  the 
gastric  secretion,  and  this  condition  is 
further  harmful  in  that  the  essential 
element  for  pancreatic  secretion  is  pro- 
duced only  under  the  stimulus  of  the 
acid  chyme  passing  over  the  duodenal 
mucosa.  To  cause  an  artificial  diges- 
tion, pancreatic  as  well  as  gastric,  hy- 
drochloric   acid    and    pepsin    in    much 


larger  doses  than  are  usually  considered 
permissible  prove  effective.  In  a  per- 
sonal case,  the  patient  received  30  grains 
of  pepsin  and  105  minims  of  dilute  hy- 
drochloric acid  three  times  a  day,  the 
latter  being  given  in  IS-minim  doses 
every  ten  minutes  in  albumin  water  to 
disguise  the  taste.  The  fact  that  the 
acid  was  given  combined  instead  of 
free  did  not  affect  its  action.  The  fur- 
ther treatment  consisted  in  daily  irri- 
gations of  the  colon  and  a  liberal 
mixed  diet.  It  was  shown  from  the 
blood  examination  that  the  treatment 
had  been  followed  by  most  satis- 
factory results.  Julius  Rudisch  (Med. 
Rec,  March  5,  1910). 

The  use  of  bone-marrow,  intro- 
duced by  Fraser,  has  given  good  re- 
sults in  some  cases  and  no  results 
whatever  in  others.  Freshly  prepared 
each  day  with  an  equal  quantity  of 
glycerin,  red  marrow,  1  or  2  ounces 
daily,  has  seemed  to  give  the  best  re- 
sults. It  should  be  tried  only  where 
arsenic  has  failed. 

Transfusion  of  blood  should  never 
be  omitted  when  improvement  does  not 
follow  the  administration  of  arsenic. 
The  best  method  is  that  employed  by 
Brakenridge,  of  Edinburgh.  The  blood 
is  kept  fluid  by  admixture  with  one- 
third  part  of  its  bulk  of  a  1:20  (5 
per  cent.)  solution  of  phosphate  of 
soda  in  distilled  water  kept  at  blood 
heat.  John  Duncan,  who  performed 
the  transfusions  in  Brakenridge's 
cases,  insists  upon  the  necessity  of 
slowness  in  operating.  He  regards 
thirty  minutes  as  the  minimum  time 
that  should  be  occupied  in  injecting  8 
ounces  of  the  fluid. 

Case  in  which  such  a  rapid  trans- 
formation in  the  general  condition  and 
in  the  blood-picture  followed  the 
transfusion  of  blood  that  it  is  impos- 
sible to  ascribe  the  phenomena  ob- 
served to  a  mere  coincidence.  The 
technique  was  as  follows:  Injection 
of  about  325  Gm.  of  defibrinated  blood 


ANEMIA,    PERNICIOUS    PROGRESSIVE    (HENRY). 


643 


into  the  median  vein  of  the  patient, 
about  250  c.c.  actually  entering  the 
vein.  There  was  no  disturbance  at 
the  time,  but  a  chill  occurred  in  thirty 
minutes  with  transient  rise  in  tem- 
perature. The  improvement  com- 
menced the  next  day  and  the  curves 
appended  showed  the  transformation, 
the  hemoglobin  running  up  to  75  per 
cent,  and  the  reds  from  985,000  to 
3,720,000  in  one  month.  The  prin- 
cipal danger  from  therapeutic  trans- 
fusion of  blood  lies  in  the  loss  of 
vitality  of  the  red  corpuscles.  They 
die  if  they  are  heated  too  much;  con- 
sequently the  blood  to  be  injected 
must  never  be  warmed  over  45°  C. 
They  also  die  if  they  remain  too  long 
outside  the  body,  although  they  may 
be  kept  on  ice  up  to  seventy-two 
hours.  If  blood  is  used  from  persons 
requiring  therapeutic  venesection  on 
account  of  eclampsia,  uremia,  or 
edema  of  the  lungs,  there  is  a  pos- 
sibility that  such  blood  may  prove 
injurious,  and  there  is  also  a  pos- 
sibility of  transmission  of  consti- 
tutional disease.  As  the  fibrin-fer- 
ment is  released  by  the  destruction  of 
white  corpuscles,  blood  unusually  rich 
in  leucocytes  should  never  be  used  for 
transfusion.  Sachs  (Zeit.  f.  Geburts. 
u.  Gynak.,  Bd.  Ixiv,  Nu.  2,  1909). 

Seven  cases  in  which  threatening 
anemia  was  benefited  to  a  remarkable 
extent  by  transfusion  of  only  5  c.c.  of 
human  blood.  The  transfusion  of  this 
small  amount  is  simple  and  generally 
harmless,  but  in  a  few  cases  there  were 
signs  of  mild  disturbances  after  the 
transfusion.  It  seems  as  if  the  blood 
from  certain  persons  displays  more 
toxicity  than  from  others,  3  patients 
injected  with  a  certain  blood  all  pre- 
senting the  same  transient  disturbances. 
It  was  never  noticed  that  when  two  or 
more  patients  received  blood  from  the 
same  source  the  one  presented  dis- 
turbance and  the  other  did  not.  A. 
Weber  (Deut.  Archiv  f.  klin.  Med., 
Sept.  4,  1909). 

No  actual  progress  has  been  realized 
of  late  in  treatment  of  pernicious 
anemia.  The  trouble  is  seldom  recog- 
nized early  enough  for  eflfectual  treat- 


ment, but  the  writer's  experience  with 
4  cases  seems  to  confirm  the  possible 
benefit  from  transfusion  of  small 
amounts  of  dclibrinated  blood  injected 
into  the  gluteal  muscles.  The  writer 
obtained  very  favorable  results  from 
such  injections.  The  first  patient  was 
a  woman  teacher  with  symptoms  of 
severe  pernicious  anemia  for  three 
years.  After  14  injections  of  10  or  20 
and  up  to  50  c.c.  of  blo«.d  in  the  course 
of  eleven  weeks,  the  reds  increased 
from  1,200,000  to  4,500,000  and  the 
hemoglobin  from  18  to  92  per  cent.  The 
benefit  was  equally  striking  in  the  case 
of  a  man  of  41,  given  9  injections  in  less 
than  three  months,  the  reds  increas- 
ing to  5,200,000.  In  a  young  girl  with 
ordinary  anemia  and  chlorosis  the 
hemoglobin  increased  from  40  to  75  per 
cent,  and  the  reds  from  3,200,000  to 
4,800,000.  The  blood  injected  subcuta- 
neously  does  not  pass  directly  into  the 
circulation  and  is  still  evident  four  or 
five  days  later  at  the  point,  the  reds 
still  retaining  largely  their  normal  shape 
and  staining  properties,  but  the  hemo- 
globin probably  lakes  out  into  the  cir- 
culation and  thus  aids  in  restoring  nor- 
mal conditions  in  the  general  blood- 
supply,  or  the  injected  blood  may  pro- 
vide certain  other  substances  lacking  in 
pernicious  anemia.  The  injections  do 
not  act  on  the  cause  of  the  anemia,  and 
arsenic  is  needed  for  this.  By-effects 
were  rare  and  slight,  merely  occasional 
painfulness  at  the  point  of  injection. 
Huber  (Deut.  med.  Woch.,  June  9, 
1910). 

Three  cases  in  which  transfusion  of 
blood  was  resorted  to.  The  trans- 
fusion proper  occupied  an  hour  or 
more,  as  a  rule.  During  that  time  the 
appearance  of  death-like  pallor  which 
these  patients  presented  changed  to  that 
of  comparative  health.  The  color  first 
reappeared  in  the  cheeks  and  tongue 
and  then  mounted  into  the  lips,  the 
conjunctivae,  and  the  skin  generally. 
The  hemoglobin  can  easily  be  followed, 
and  in  Dare's  or  Fleischl's  instru- 
ment showed  a  steadily  increasing  per- 
centage. In  the  2  favorable  cases 
this  amounted  to  an  increase  of  three 
or   four  times   the   original   percentage. 


644 


ANEMIA,    PERNICIOUS    PROGRESSIVE    (HENRY). 


There  was  a  corresponding  change  in 
the  patient's  mental  condition  and 
vitality,  which  seems,  in  patients  so 
near  to  death,  almost  miraculous.  This 
was  strikingly  true  in  the  first  case.  In 
both  favorable  cases  the  transfusion 
introduced  a  period  of  improvement 
which  in  the  first  case  has  now  lasted 
nine  months;  in  the  third,  two.  The 
hemoglobin  and  the  number  of  red  cells 
have  increased  steadily  until  80  per 
cent,  and  more  has  been  attained. 
Bovaird   (Med.  Record,  Feb.  11,  1911). 

Defibrinated  blood  has  been  used 
subcutaneously  by  Westphalen  with 
success. 

Subcutaneous  injections  of  normal 
saline  solution  every  alternate  day, 
and  on  the  intervening  saline  ene- 
mata,  with  arsenic  internally,  have 
been  recommended  by  McPhedran. 

Intestinal  antiseptics  have  been  rec- 
ommended. Hunter  holds  that  the  best 
intestinal  antiseptic  is  betanaphthol 
and  salol,  along  with  arsenic  when 
that  can  be  borne.  I  consider  thymol 
entitled  to  the  first  position,  a  fact 
which  seems  to  be  more  fully  appre- 
ciated in  Italy  than  elsewhere.  In 
accordance  with  the  view  that  perni- 
cious anemia  is  due  to  the  absorption 
from  the  intestine  of  substances  for- 
eign to  the  healthy  body,  and  de- 
structive to  the  red  corpuscles,  its 
treatment  by  intestinal  antiseptics  is 
certainly  most  rational. 

When  the  disease  is  due  to  the  Anky- 
lostoma  duodenale,  thymol,  2  to  3 
drams  daily,  is  a  very  effective  vermi- 
cide, according  to  Bozzolo. 

Two  cases  due  to  Bothriocephalus 
latus,  the  infection  being  accompanied 
by  the  severest  kind  of  anemia.  In  one 
patient  the  red  corpuscles  fell  to  780,- 
000  and  the  hemoglobin  to  15  per  cent. 
The  second  case  was  even  more  severe, 
the  red  corpuscles  falling  to  660,000  and 
the  hemoglobin  to  10  per  cent.  Hemor- 
rhages were  noted  along  the  veins  of 


the  retina.  The  improvement  in  both 
cases  after  thymol  treatment  was 
marvelous,  and  in  the  second  patient 
in  thirteen  days  the  number  of  red 
corpuscles  trebled.  A.  Meyer  (Med. 
News,  April  8,  1905).  . 

Serum  therapy  seems  to  merit  fur- 
ther trial,  though  not  much  more  than 
temporary  benefit  can  be  expected 
from  its  use. 

Antistreptococcic  serum  used  with 
gratifying  resvtlts  in  2  cases  of  anemia: 
one  pernicious,  the  other  simple.  In 
the  former,  examination  of  the  blood 
showed  4000  white  and  less  than  1,000,- 
000  red  corpuscles  to  the  cubic  centi- 
meter, and  30  per  cent,  of  hemoglobin. 
Eight  injections  of  8  c.c.  each  were 
given  at  intervals  of  two  or  three  days. 
After  the  third,  improvement  began 
and  progressed  steadily.  Three  days 
after  the  last  injection  the  blood  con- 
tained 5000  white  and  4,960,000  red  cor- 
puscles, and  90  per  cent,  of  hemoglobin. 
W.  H.  deWitt  (Cin.  Lancet-Clinic, 
Ixxxiv,  p.  61,  1900). 

Typical  case  in  a  man  37  years  of  age. 
The  treatment  consisted  of  oral  and 
gastric  antisepsis.  During  July  three 
injections  of  antistreptococcic  serum 
were  given.  After  the  first  the  red  cor- 
puscles rose  to  36  per  cent. ;  after  the 
second  to  52  per  cent.,  and  in  three 
weeks  the  red  corpuscles  rose  to  65  per 
cent,  and  the  hemoglobin  to  72  per  cent. 
In  September  arsenic  was  added  to  the 
other  treatment,  and  by  December  the 
red  corpuscles  had  risen  to  94  per  cent, 
and  the  hemoglobin  to  100  per  cent. 
William  Hunter  (Lancet,  March  30, 
1901). 

Herter  recommends  frequent  and 
thorough  irrigation  of  the  colon,  since 
it  is  the  chief  thriving  place  of  the 
anaerobic  bacteria  which  cause  the  spe- 
cific putrefaction.  Following  this  sug- 
gestion, Dittmar  and  Hollis  were  able 
to  report  a  few  months  ago  recovery  in 
2  cases  of  pernicious  anemia  by  irriga- 
tion of  the  colon  which  had  resisted 
all  other  methods  of  treatment. 


ANEMIA,    PERNICIOUS    PROGRESSIVE    (HENRY). 


645 


In  all  cases  of  pernicious  anemia,  the 
stools  should  be  examined  to  determine 
the  presence  of  a  Bacillus  capsiilatus 
acrogciics  infection.  If  these  bacteria 
are  present  in  great  quantities,  then 
high  irrigation,  combined  with  arsenic 
internally,  should  be  used;  and  if  the 
patient  fails  to  improve,  then  the  appen- 
dix offers  the  best  route  for  thorough 
irrigation.  Lucius  E.  Burch  (Jour. 
Amer.  Med.  Assoc,  March  13,  1909). 

When  the  Bacillus  capsulatus  aerog- 
eiies  or  the  percentage  of  anaerobic 
bacteria  found  in  evacuations  from 
bowels  is  large,  then,  after  thorough 
trial  at  colonic  irrigation  and  failure 
to  improve  the  symptoms  or  to  lessen 
the  percentage  of  bacteria,  the  opera- 
tion of  appendicostomy  is  warranted. 
J.  A.  Witherspoon  (Southern  Med. 
Jour.,  July,  1909). 

Cholesterin  has  been  introduced 
into  the  therapy  of  pernicious  anemia 
because  of  Ransom's  finding  that  it 
prevented  the  hemolytic  efTects  of 
some  substances,  such  as  saponin  and 
cobra  poison.  A  3  per  cent,  solution 
of  cholesterin  in  oil  is  given  in  100- 
Gm.  (3%  ounces)  doses  daily.  It  is 
apt,  however,  to  disagree  with  the 
patient. 

The  objections  to  the  use  of  choles- 
terin consist  mainly  in  the  fact  that 
this  substance  is  not  at  all  decreased  in 
the  blood  of  the  patients,  but  is  often 
increased  above  the  normal  figures. 
Cholesterin  in  3  per  cent,  solution  in 
oil  was  given  by  the  writer,  but  this 
disagreed  with  most  patients.  The 
feeding  of  milk,  cream,  and  butter, 
however,  accomplishes  the  same  results 
by  increasing  the  fat  and  the  choles- 
terin contents  in  the  blood.  Large 
amounts  of  these  substances  were  used 
in  the  diet,  and  the  results  were  very 
favorable,  though  it  is  impossible  to. say 
whether  the  cholesterin  had  anything 
to  do  with  it.  Arsenical  preparations 
were  also  given.  Klemperer  (Berl. 
klin.  Woch.,  Nu.  52,  1908). 

Cholesterin  tried  in  6  typical  cases 
of  cryptogenetic  pernicious  anemia,  one 


of  them  being  of  the  so-called  aplastic 
type.  Three  patients  were  in  an  ad- 
vanced state  of  the  disease  when  com- 
ing under  observation  and  only  lived 
for  a  few  weeks ;  in  these  no  effect 
whatever  was  observed  from  the  use 
of  the  cholesterin.  A  fourth  patient 
was  discharged  unimproved  after  a 
three  weeks'  course  of  the  treatment 
and  died  a  few  days  later.  In  the  fifth 
only  24  Gm.  had  been  administered 
when  the  treatment  was  suspended,  and 
death  occurred  shortly  thereafter. 

An  apparently  beneficial  effect  was 
obtained  in  the  remaining  case,  but,  as 
the  patient  at  the  time  when  the  choles- 
terin treatment  was  begun  was  virtually 
in  her  first  attack,  one  naturally  hesi- 
tates to  ascribe  the  noted  improvement 
to  any  one  therapeutic  factor.  It  is 
noteworthy,  however,  that  the  resump- 
tion of  the  cholesterin  some  months 
later,  when  a  relapse  had  occurred,  was 
again  followed  by  marked  improvement. 
This  patient  is  still  living  and  in  good 
condition.  When  first  seen  the  red 
cells  numbered  1,744,000,  while  the 
hemoglobin  was  46  per  cent. ;  there  was 
then  marked  anisocytosis  with  a  dis- 
tinct tendency  to  macrocytosis ;  there 
were  poikilocytosis  and  extensive  granu- 
lar degeneration  (so-called).  C.  E. 
Simon  (Jour.  Amer.  Med.  Assoc,  Dec. 
19,  1908). 

Three  cases  of  pernicious  anemia  and 
1  of  secondary  anemia  referable  to 
nephritis  in  which  cholesterin  was 
used  for  therapeutic  purposes,  the 
aim  being  to  counteract  any  hemoly- 
sins that  might  be  active  in  a  manner 
analogous  to  the  action  of  cholesterin 
on  cobra  lecithide.  Of  the  3  cases,  one 
patient  remained  unimproved,  while 
in  the  other  two  cholesterin  was  de- 
cidedly beneficial.  The  latter  case  was 
in  a  wretched  condition,  with  intense 
dyspnea,  ascites,  pleural  effusion, 
edema,  and  a  red  count  of  750,000 
with  18  per  cent,  of  hemoglobin. 
After  a  week  the  count  had  risen  to 
1,750,000  and  the  hemoglobin  to  30 
per  cent.,  while  the  threatening  symp- 
toms had  all  disappeared.  The  im- 
provement was  thus  quite  remark- 
able, but  after  a  few  weeks  no  further 


646 


ANEMIA,    SECONDARY    (DA  COSTA). 


gain  was  obtained  and  still  later  a  re- 
lapse occurred  which  ended  fatally. 
Reicher  (Berl.  klin.  Woch.,  Nu.  41-42, 
1908). 

Glycerin  has  also  been  tried  in  para- 
sitic pernicious  anemia,  as  a  result  of 
Tallquist  and  Faust's  .  suggestion  that 
glycerin  might  combine  with  the  lipoid 
substance  assumed  to  be  responsible 
for  the  disintegration  of  the  red  cor- 
puscles and  thus  combine  to  form  a 
harmless  product.  The  special  lipoid 
substance  found  in  the  anemia  from  in- 
testinal parasites  proved  to  be  oleic 
acid,  and  this  combines  with  glycerin 
to  form  triolein. 

In  the  first  of  2  cases  in  which  glyc- 
erin was  tried,  the  result  was  very- 
encouraging,  and  in  the  second  admin- 
istration of  3  tablespoonfuls  of  glyc- 
erin a  day,  with  lemon  juice,  was  fol- 
lowed in  the  course  of  two  and  a  half 
months  by  an  increase  in  the  red  cor- 
puscles from  990,000  to  4,760,000,  and 
of  hemoglobin  from  20  to  90  per  cent. 
No  other  drugs  were  given,  except  a 
little  antipyrin  and  cafifeine,  for  a  day 
or  so  to  combat  a  neuralgic  headache. 
Vetlesen  (Norsk  Mag.  f.  Laeger,  Oct., 
1909). 

Case  in  which  there  were  only  970,- 
000  red  and  4000  whites,  with  20  per 
cent,  hemoglobin.  Death  seemed  im- 
minent when  a  tablespoonful  of  glyc- 
erin was  given  three  times  a  day  at 
first,  and  later  up  to  70  Gm.  The 
man,  a  syphilitic  in  whom  the  iodides 
and  mercury  had  been  tried,  began 
to  improve  at  once  and  by  the  end  of 
a  month  the  reds  numbered  4,200,000, 
the  whites  5300,  with  100  per  cent, 
hemoglobin.  This  confirms  Tall- 
quist's  experience  in  a  similar  case. 
Both  patients  seem  to  be  permanently 
cured: 

The  writer's  patient  is  still  taking 
glycerin,  but  is  strong  and  well. 
Muktedir  (Deut.  med.  Woch.,  May 
18,  1911). 

Frederick  P.  Henry, 

Philadelphia. 


ANEMIA,  SECONDARY,  OR 
SYMPTOMATIC.  —     D  E  F I N I  - 

TION,  —  A  deficiency  either  in  the 
quantity  or  the  quality  of  the  blood, 
affecting  the  blood  mass  or  the  cellular 
and  albuminous  constituents.  Genuine 
secondary  anemia  is  essentially  a  symp- 
tomatic disorder,  referable  to  obvious 
pathological  conditions,  which  deplete 
the  blood  volume,  diminish  the  number 
of  erythrocytes,  and  reduce  the  amount 
of  hemoglobin  and  albumin. 

["Anemia,"  "Primary"  or  "Idiopathic 
Anemia"  are  now  obsolete  as  designations, 
all  anemias  being,  in  the  light  of  modern 
research,  due  to  some  underlying  cause — ■ 
though  many  of  these  are  still  undetermined 
■ — and  therefore  "secondary"  or  "symptom- 
atic." Hence  the  above  heading  and  defini- 
tion.   The  Editors.] 

TYPES      OF     SECONDARY 

A  N  E  M  I  A. — It  is  convenient  to 
classify  the  simple  secondary  anemias 
into  several  clinical  groups  which 
relate  directly  to  the  predominant 
factor  active  in  the  individual  case. 
While  a  classification  of  this  sort 
must  needs  be  imperfect,  for  fre- 
quently several  factors  are  concerned 
in  a  single  instance,  it  will  serve  to 
designate  the  important  underlying 
condition  of  which  the  blood  im- 
poverishment is  symptomatic.  The 
following  groups  are  sufficient  for  the 
inclusion  of  all  anemias  of  secondary 
origin:  I,  posthemorrhagic;  II,  infec- 
tious and  toxic,  and.  III,  trophic. 

I.  Posthemorrhagic  anemias  com- 
prise that  varied  class  of  cases  directly 
traceable  to  bleeding,  irrespective  of 
its  extent,  duration,  and  character. 
In  this  group,  therefore,  are  included 
the  acute  anemias  due  to  loss  of  blood 
by  trauma,  operation,  abortion,  par- 
turition, epistaxis,  hemoptysis,  gastric 
and    intestinal    ulcer    and    neoplasm, 


ANEMIA,    SECONDARY    (DA  COSTA). 


647 


hemorrhagic  pancreatitis,  and  under 
the  same  heading  are  the  grave  ane- 
mias consecutive  to  the  rupture  of 
an  aneurism,  of  a  Fallopian  tube,  and 
of  a  large  mass  of  varicose  veins. 
The  hemorrhagic  diseases  (purpura, 
hemophilia,  scurvy),  hemorrhoids, 
and  uterine  fibroids,  all  of  which  are 
capable  of  causing  persistent,  though 
perhaps  moderate,  loss  of  blood,  may 
also  excite  a  secondary  anemia,  per- 
haps of  pronounced  severity. 

II.  Infectious  and  toxic  anemias 
develop  chiefly  as  the  result  of  hemo- 
lytic agencies,  and  are  encountered  in 
the  specific  infections,  malignant  dis- 
ease, intestinal  helminthiasis;  in  poi- 
soning by  certain  so-called  blood 
poisons — nitrobenzol,  potassium  chlo- 
rate, lead,  mercury,  arsenic,  antimony; 
and  in  states  of  autointoxication — 
uremia,  cholemia,  pregnancy.  Of  the 
acute  febrile  infections  that  account 
for  anemia  of  moderate  intensity, 
enteric  fever,  sepsis,  variola,  erysipe- 
las, rheumatic  fever,  and  scarlatina 
may  be  named  as  typical  examples. 
The  anemia  excited  by  malignant 
neoplasms  is  attributable  partly  to 
the  action  of  circulating  tumor-toxins 
and  partly  to  concomitant  factors, 
such  as  hemorrhage,  ulceration,  and 
interference  with  nutrition,  as  in 
esophageal  and  gastric  growths.  The 
anemia  of  helminthiasis  is  due  prin- 
cipally to  the  hemolytic  action  of 
poisonous  substances  elaborated  by 
the  worm,  notably  in  the  case  of 
uncinariasis  and  bothriocephaius  dis- 
ease, and  to  a  less  extent  in  persons 
harboring  oxyurides,  ascarides,  .and 
filariae.  Helminthiasis  anemia  is  also 
favored  by  the  associated  gastroin- 
testinal disorders,  and,  in  uncinari- 
asis, the  parasites  suck  blood  from 
the  intestinal  vessels  of  the  host  and 


pour  out  an  absorbable  anticoagulant 
material  which  may  act  deleteriously 
upon  the  circulating  blood-cells.  The 
luetic  virus  materially  damages  the 
hemoglobin  and  erythrocytes,  and 
syphilitics  as  a  class  are  subject  to  a 
form  of  toxic  anemia  which  as  a  rule 
attains  its  greatest  development  dur- 
ing the  tertiary  stage  of  the  infection. 
In  malarial  fever  it  is  probable  that 
the  presence  of  a  circulating  specific 
malarial  toxin,  produced  by  myriads 
of  parasites,  has  much  to  do  with 
provoking  the  attendant  anemia,  and 
it  is  certain  that  in  this  infection 
the  blood  must  sufifer  from  the  whole- 
sale destruction  of  parasitiferous  eryth- 
rocytes. 

There  is  a  type  of  apparent  anemia 
which  is  often  mistaken  for  real 
chlorosis,  until  an  examination  of  the 
blood  shows  that  the  number  of  red 
corpuscles  and  the  percentage  of  hemo- 
globin are  normal.  In  such  cases  the 
writer  thinks  a  history  of  past  or  pres- 
ent tuberculous  disease  can  always  be 
found.  This  condition  was  recognized 
by  Trousseau,  and  was  called  by  him 
"false  chlorosis"  or  "tuberculous  ane- 
mia." Several  cases  of  this  condition 
are  cited  in  detail.  In  treatment,  iron 
is  to  be  avoided,  and  open  air  and 
hygiene  are  important.  A.  James  (Brit. 
Med.  Jour.,  Dec.  28,  1907). 

Insufficiency  of  the  blood-forming 
function  is  not,  primarily  at  least,  at 
fault  in  the  production  of  the  secondary 
anemias  following  chronic  gastrointes- 
tinal disease.  The  writer  considers  the 
anemia  more  probably  due  to  the  ex- 
istence in  the  blood-serum  of  hemolytic 
substances,  perhaps  produced  by  chem- 
ical changes  connected  with  functional 
disturbances  in  the  digestive  organs. 
Besides  the  indirect  pathological  evi- 
dence of  the  existence  of  such  hemo- 
lytic action,  the  writer  has  been  able  to 
demonstrate  it  directly  by  the  action 
of  the  serum  of  anemic  rabbits  on  the 
blood  of  normal  ones.  With  its  globu- 
licidal  power  it  has  a  certain  stimulant 


648 


ANEMIA,    SECONDARY    (DA  COSTA). 


action  on  the  blood-forming  apparatus 
in  the  bane-marrow,  which,  however, 
seems  to  be  more  quickly  exhausted 
than  is  its  destructive  action.  The 
author  considers  that  his  study  empha- 
sizes the  importance  of  functional  over 
anatomical  gastric  lesions  in  the  produc- 
tion of  anemia.  Tixier  (Semaine  med., 
June  19,  1907). 

Cultures  of  dysentery,  colon,  and 
typhoid  bacilli  grown  upon  agar  sus- 
pended in  salt  solution  and  then  ex- 
tracted with  alcohol  at  37°  C. ;  these  ex- 
tracts were  found  to  have  a  slight 
hemolytic  power  for  dogs'  blood  in 
vitro.  When  injected  into  rabbits  these 
extracts  produced  a  distinct,  but  mod- 
erate anemia.  An  attempt  was  then 
made  to  increase  the  hemolytic  activity 
of  these  organisms  by  enhancing  their 
virulence.  For  this  purpose  irritation 
of  the  gastrointestinal  tract  was 
brought  about  in  dogs  and  rabbits  by 
means  of  chemicals,  and  later  large 
quantities  of  cultures  of  the  organisms 
were  introduced  into  the  stomach. 
Twenty-four  to  forty-eight  hours  after 
the  intestinal  infection  had  been  set  up 
the  animals  were  killed  and  the  organ- 
isms recovered  again  from  the  intes- 
tinal tract.  Extracts  of  the  organisms 
which  had  caused  these  intestinal  in- 
fections were  found  to  have  increased 
considerably  in  hemolytic  activity  in 
vitro.  When  the  extracts  were  inocu- 
lated into  dogs  and  rabbits  a  marked 
and  rapid  anemia  developed,  with  re- 
duction in  both  hemoglobin  and  red 
corpuscles.  Fejes  (Deut.  Arch.  f.  klin. 
Med.,  Bd.  cii,  S.  129,  1911). 

III.  Trophic  anemias,  or  those  of 
nutritional  origin,  are  met  with  com- 
monly in  subjects  that  suffer  from 
chronic  malnutrition  due  to  faults  in 
the  quantity  and  quality  of  their 
food,  to  defective  absorption  and 
assimilation,  or  to  a  combination  of 
these  two  causes,  and  in  many  such 
instances  deficient  air  and  sunshine, 
lack  of  exercise,  confining  occupation, 
and  unsanitary  surroundings  must 
likewise  be   reckoned  with   as  contrib- 


uting elements.  Drains  upon  the 
albumins  of  the  system,  as  in  habit- 
ual nephritis,  persistent  suppuration, 
prolonged  lactation,  and  chronic  dys- 
entery, ultimately  provoke  well-de- 
fined, stubborn  anemia  of  the  trophic 
type. 

Congenital  anemia  is  sometimes  due 
to  heredity.  Habitual  anemia  of  the 
parents,  cachexia  as  a  result  of  tuber- 
culosis, malignant  neoplasms,  diseases 
during  pregnancy,  poor  nutrition  and 
lack  of  hygiene,  may  all,  according  to 
the  author,  give  rise  to  anemia  in  the 
child.  The  anemia  is  transmitted  by 
means  of  the  placental  circulation  and 
continues  to  develop  in  the  fetus  in 
utero.  The  alimentary  form  when 
present  in  the  non-anemic  newborn  is 
due  to  an  exclusive  milk-diet  which  in 
itself  is  deficient  in  iron.  L.  Fiirst 
(Therap.  Monats.,  Nu.  9,  1900). 

An  anemia  is  often  observed  in  young 
children  that  is  due  to  improper  feed- 
ing. This  may  consist  of  carelessly 
prepared  artificial  food,  bad  quality  of 
milk,  irregularity  of  feedings,  the  use 
of  too  large  quantities  of  food,  the  use 
of  solid  food  before  the  age  of  9 
months,  stimulating  drinks,  insufficient 
nursing,  brutal  weaning,  and  the  abuse 
of  milk  after  weaning.  The  writer 
believes  that  this  form  of  anemia  is 
more  frequent  in  young  children  than 
the  anemia  of  tuberculosis,  of  syphilis, 
of  malaria,  or  of  lymphadenia.  Rougier 
(Paris  Thesis,  No.  13,  1901-1902;  Gaz. 
heb.  de  med.  et  de  chir.,  Feb.  9,  1902). 
In  patients  with  insufficient  or  absent 
secretion  of  gastric  juice  there  is  al- 
ways evidence  of  anemia.  In  hyper- 
acidity the  hemoglobin  was  found  above 
normal,  and  in  nervous  dyspepsia  it  was 
practically  normal.  Only  in  the  cases 
ranging  from  subacid  gastritis  to  gas- 
tric achylia  was  anemia  the  constant 
finding.  The  writer's  experience  fur- 
ther demonstrated  that  administration 
of  natural  gastric  juice  from  the  dog, 
supplying  the  missing  element  for  gas- 
tric digestion,  was  followed  by  the 
subsidence  of  the  anemia.  The  sup- 
plementary gastric  juice  insured  proper 


ANEMIA,    SECONDARY    (DA  COSTA). 


649 


nourishment  for  the  ckincnls  of  the 
blood.  F.  RoHin  (I'.erl.  klin.  Woch., 
Bd.  xliii,  Nu.  5.   1904). 

In  the  majority  of  cases  of  serious 
anemia  anhematopoiesis  is  not  ana- 
tomically demonstrable,  and  there  is 
usually,  if  not  always,  the  destruction 
of  the  blood  which  is  related  to  de- 
globulization.  That  is  to  say,  in  most 
cases  of  anemia  the  study  of  the  an- 
hematopoiesis should  not  lead  one  to 
forget  the  investigation  of  the  causes 
of  the  anemia,  the  mechanism  of  the 
destruction  of  the  blood-globules,  which 
is  of  great  importance  from  both  the 
pathogenic  and  therapeutic  points  of 
view.  C.  Aubertin  (La  semaine  med., 
July  IS,  1908). 

In  severe  anemias  experimentally 
produced  the  oxidations  in  the  tissues 
are  not  carried  out  completely  to  the 
final  products  of  metabolism,  but  are 
brought  to  an  end  partly  in  the  blood 
or  in  other  organs.  The  true  cause 
may  therefore  be  lack  of  oxygen. 
Morawitz  and  Pratt  (Miinch.  med. 
Woch.,  Sept.  1,  1908). 

The  writer  refers  to  the  anemia  with- 
out appreciable  cause,  and  experience 
has  convinced  him  that  these  anemic 
infants  are  suffering  from  lack  of  iron. 
This  form  of  anemia  is  more  common 
in  families  in  which  the  infants  are 
allowed  nothing  but  milk,  while  it  is 
rare  when  the  children  early  eat  at  the 
family  table.  He  does  not  give  iron 
directly,  but  during  or  after  the  third 
month  allows,  once  a  day  a  little  meat 
broth  with  one-half  and  later  the  whole 
yolk  of  an  egg.  During  the  fourth  and 
fifth  months  gruel  is  given  once  or 
twice  a  day,  made  of  zwieback  with 
butter,  milk,  salt,  and  sugar,  to  which 
the  egg-yolk  is  added.  By  the  sixth  or 
ninth  month  he  gives  spinach;  by  the 
tenth  and  eleventh  months  a  small 
amount  of  meat. 

When  the  child  is  a  year  old  he 
reduces  the  milk  to  a  pint  or  a  pint  and 
one-half  a  day  and  accustoms  the  child 
to  a  mixed  diet.  By  this  means,  the 
anemia  is  prevented  and  always  cured 
when  developed.  Infants  seem  to  feel 
the  need  of  iron  mostly  in  the  fourth 
month,  and  by  giving  them  in  this  way 


a  little  food  that  contains  iron  it  is 
possible  to  keep  the  hemoglobin  at  100 
per  cent.  The  children  take  this  diet 
without  disturbance.  Yolk  of  egg  and 
spinach  contain  22  and  35  mg.  iron  in 
100  Cm.  of  dry  substance,  while  cows' 
milk  contains  only  2.3  mg.  The  writer 
thinks  it  is  not  a  mere  coincidence  that 
none  of  the  children  given  iron  in  this 
way  has  ever  developed  rachitis.  Milk 
does  not  contain  enough  iron  for  the 
proper  development  of  the  infant,  and 
sooner  or  later  the  child  will  suffer, 
especially  about  the  fourth  or  sixth 
month,  at  which  time  a  little  mixed 
food  containing  iron  is  given  whether 
the  child  is  getting  breast  milk  or  is 
bottle-fed.  J.  Katzenstein  (Miinch. 
med.  Woch.,  Aug.  10,  1909 ;  Jour  Amer. 
Med.  Assoc,  Sept.  18,  1909). 

PATHOLOGY.— The  principal 
pathologic  alterations  incident  to  ane- 
mias of  the  secondary  type  relate  to  the 
composition  of  the  circulating  blood 
and  to  the  histology  of  the  bone-mar- 
row, of  which  the  former  changes  are 
the  more  important,  and,  obviously, 
more  readily  available  to  the  clinician. 
The  blood  changes  vary  within  wide 
limits,  depending  upon  the  grade  and 
the  chronicity  of  the  individual  case; 
but  in  general  it  may  be  stated  that 
they  are  of  very  moderate  intensity  in 
the  average  example  of  general  symp- 
tomatic anemia.  There  is  a  more  or 
less  decided  diminution  in  the  number 
of  erythrocytes  (oligocythemia),  with  a 
tolerably  proportionate  reduction  in  the 
percentage  of  hemoglobin  (oligochro- 
memia),  and,  in  severe  cases,  one  ob- 
serves structural  changes  implicating 
the  erythrocytes'  stroma  and  eventually 
leading  to  the  production  of  corpuscular 
deformities  of  shape  (poikilocytosis) , 
and  of  size  (megalocytosis;  micro- 
cytosis).  Not  always,  however,  is  the 
hemoglobin-erythrocyte  reduction  pro- 
portionate, for  in  some  forms  of  sec- 
ondary anemia  the  hemoglobin  loss  is 


650 


ANEMIA,    SECONDARY    (DA  COSTA). 


greatly  disproportionate  to  that  of  the 
cells,  as,  for  example,  in  so-called 
"syphilitic  chlorosis,"  which,  hemat- 
ologically,  counterfeits  maiden's  chlo- 
rosis; on  the  contrary,  in  other  types 
the  erythrocytes  suffer  chiefly,  as  in 
that  variety  of  parasitic  anemia  pro- 
voked by  the  Bothriocephalus  latus, 
which  apes  true  pernicious  anemia  in 
every  detail  of  the  blood-picture. 
These  facts  call  for  great  caution  in 
attempting  to  diagnose  a  secondary 
anemia  by  the  blood  changes  alone, 
without  due  regard  for  the  discovery 
of  some  adequate  causal  factor  to 
be  correlated  therewith.  In  active, 
severe  cases  of  anemia  young,  nu- 
cleated erythrocytes  (normoblasts)  es- 
cape prematurely  from  the  bone- 
marrow  and  appear  in  the  circulating 
blood  in  limited  numbers,  and  in  the 
event  of  intense  retrograde  marrow 
changes  an  occasional  nucleated  cor- 
puscle of  fetal  type  (megaloblast)  also 
may  be  observed.  With  such  evidences 
of  high-grade  blood  deterioration  one 
also  meets  with  cells  disfigured  by 
atypical  staining  proclivities  (polychro- 
matophilia),  and  with  cells  whose  proto- 
plasm is  stippled  with  fine  and  coarse 
basic  granules  {granular  basophilia), 
both  of  which  abnormal  findings 
point  to  a  considerable  degree  of 
stroma  degeneration,  whereby  the 
affected  cells  no  longer  react  toward 
acid  aniline  dyes,  as  they  do  normally, 
but  show  a  selective  affinity  for  basic 
colors,  by  which  the  stroma  of  the 
healthy  red  corpuscle  is  never  stained, 
when  exposed  to  a  mixture  contain- 
ing both  acid  and  basic  dyes.  The 
behavior  of  the  leucocytes  in  second- 
ary anemias  is  most  inconstant.  In 
chronic  cases,  especially  those  due  to 
trophic  defects,  and  in  certain  of  the 
slowly  progressive  toxic  anemias  the 


leucocyte  count  does  not  deviate 
from  normal,  or,  if  it  shows  any  ap- 
preciable change,  becomes  subnormal 
{leucopenia).  In  these  leucopenic  ane- 
mias it  is  also  the  rule  to  find  a  dis- 
proportionately high  percentage  of 
lymphocytes  {relative  lymphocytosis), 
these  cells  increasing  in  number 
chiefly  at  the  expense  of  the  poly- 
nuclear  forms. 

The  writer  using  Wright's  modifica- 
tion of  Leishmann's  stain,  in  studying 
the  blood  from  cases  of  anemia,  ob- 
served peculiar  stained  ring  formations 
within  certain  of  the  red  blood-cor- 
puscles. These  figures  were  seen  in 
3  cases  of  pernicious  anemia,  4  of  lead 
poisoning,  and  1  of  lymphatic  leukemia. 
Unlike  the  ordinary  basophilic  granula- 
tions found  so  often  in  the  red  blood- 
cells  from  cases  of  lead  poisoning  and 
pernicious  anemia,  these  figures  stained 
not  blue,  but  bright  red.  The  rings 
were  quite  perfect.  They  varied  in 
size :  in  some  instances  being  very 
small,  in  others  encircling  the  extreme 
periphery  of  the  corpuscle.  Rarely 
they  were  twisted  or  had  a  figure-of- 
eight  form.  Occasionally  basophilic 
granulations  were  noted  in  the  same 
corpuscle  which  contained  a  ring  body. 
Such  figures  did  not  appear  in  blood 
specimens  stained  with  hematoxylin. 
The  author  believes  that  they  may  be 
connected  in  some  manner  with  cell 
regeneration,  and  suggests  that  they 
'  may  represent  nuclear  remains,  or,  per- 
haps, portions  of  the  nucleus  which 
have  resisted  those  forces  destructive 
to  it,  and  ultimately  to  the  cell  itself. 
Cabot  (Jour,  of  Med.  Research,  vol. 
ix,  p.  15,  1903). 

Effort  to  reproduce  in  the  lower 
animals  by  repeated  bleedings  his- 
tological changes  analogous  to  those 
occurring  in  the  aplastic  anemia  of  man. 
The  experiments  were  carried  out  upon 
dogs  and  rabbits.  The  dogs  were  bled 
daily  from  a  vein,  over  a  considerable 
period  of  time ;  with  the  rabbits  leeches 
were  used  to  remove  the  blood.  Young 
animals  were  found  to  be  suitable  for 
the   work  because  of  the   rapidity  with 


ANEMIA,    SECONDARY    (DA  COSTA). 


651 


which  their  blood  is  regenerated  after 
hemorrhage.  In  older  animals,  in 
which  the  hematopoiesis  is  less  active 
the  bone-marrow  showed  only  slight 
hyperplasia;  this  was  of  the  myelo- 
blastic  type — the  predominating  cell 
being  mononuclear  and  non-granular, 
nucleated  red  blood-cells ;  granulocytes 
were  very  few  in  number.  In  the 
spleen  megalokaryocytes  were  found, 
but  no  evidences  of  blood  formation 
were  observed  here.  In  one  instance 
the  spleen  contained  numerous  phago- 
cytes filled  with  red  cells.  No  signs  of 
blood  formation  were  observed  in  the 
liver.  The  peripheral  blood,  which  was 
frequently  examined,  resembled  that 
seen  in  aplastic  anemia  in  man  in  the 
absence  of  poikilocytosis  and  the  small 
number  of  nucleated  red  blood-cells, 
and  differed  from  it  in  the  presence 
of  basophilic  granules  and  polychroma- 
tophilia  in  the  red  cells,  and  in  the 
absence  of  leucopenia  and  lympho- 
cytosis. The  basophilic  granules  of  the 
erythrocytes  the  writers  look  upon  as 
nuclear  in  origin ;  the  granules  were 
found  in  the  blood  of  those  animals  in 
which  regeneration  was  most  active; 
they  were  not  found  in  association  with 
aplastic  bone-marrow,  evidence  of  their 
nuclear  source.  Blumenthal  and  Mora- 
witz  (Deut.  Archiv  f.  klin.  Med.,  Bd. 
xcii,  S.  25,  1907). 

Case  in  which  the  presence  of  peculiar 
red  corpuscles  was  evidently  chronic  as 
revealed  by  the  history  of  the  past 
three  years,  with  yaws  and  suppurating 
otitis  as  predecessors,  yet  with  acute 
exacerbations.  The  condition  was  not 
clearly  explained  on  the  basis  of  an 
organic  lesion  in  any  one  organ.  There 
was  cardiac  enlargement,  albuminuria, 
and  cylindruria,  general  adenopathy, 
icterus,  with  a  secondary  anemia  not 
remarkable  for  the  great  reduction  in 
red  corpuscles  or  hemoglobin,  but 
strikingly  atypical  in  the  large  number 
of  nucleated  red  corpuscles  of  the  nor- 
moblastic type  and  in  the  tendency  of 
the  erythrocytes  to  assume  a  slender 
sickle-like  shape.  The  leucocytosis  with 
a  rather  high  eosinophile  count  was  also 
noted.  Syphilis  was  suggested  by  many 
of  the    facts,    such    as   adenopathy   and 


the  conditions  of  the  heart  and  kid- 
neys ;  it  might  explain  the  anemia,  the 
arthritis  and  perhaps  also  the  tempera- 
ture, cough,  and  attacks  of  pain  re- 
sembling hepatic  or  gall-bladder  dis- 
ease; for,  as  is  well  known,  visceral 
syphilis  may  furnish  a  most  bizarre 
group  of  symptoms.  The  Wassermann 
test  was  not  in  use  at  this  time.  The. 
scars  said  to  have  been  due  to  yaws 
were  like  those  left  by  syphilis.  The 
patient  coming  from  the  tropics,  one 
thought  of  intestinal  parasites  such  as 
uncinaria  as  a  possible  explanation  of 
the  anemia  and  the  eosinophilia.  What 
were  thought  to  be  eggs  were  found  on 
one  occasion  only,  and  after  thymol 
there  was  temporary  improvement.  The 
odd  blood-picture  made  one  examine 
for  possible  toxic  effects  of  the  coal- 
tar  preparations,  but  neither  from  the 
history  nor  from  the  examination  of 
the  urine  was  there  any  evidence  that 
such  drugs  were  habitually  taken.  The 
question  of  diagnosis,  therefore,  re- 
mains an  open  one  unless  reports  of 
other  similar  cases  with  the  same 
peculiar  blood-picture  shall  clear  up 
this  feature.  Herrick  (Archives  of 
Intern.  Med.,  Nov.,  1910). 

Other  anemic  blood  changes,  of 
very  minor  importance,  comprise  in- 
creased rapidity  of  clotting  and  sub- 
normal specific  gravity  values. 

Anemia  appearing  in  the  face  of 
active  hemorrhage,  of  acute  infectious 
processes,  and  of  malignant  disease  is 
ordinarily  attended  by  a  leucocyte 
increase  affecting  mainly  the  poly- 
nuclear  cells  ipolynuclear  neutrophile 
leucocytosis),  and  in  helminthetic  dis- 
eases of  recent  origin  there  is  a  very 
constant  increase  in  the  percentage  of 
eosinophile  cells  (polyniiclear  eosino- 
phile leucocytosis).  The  presence  of 
small  numbers  of  immature  polynuclear 
neutrophile  cells  (myelocytes)  in  the 
blood  is  frequently  noted  in  many  of 
the  severer  anemias  of  symptomatic 
character,  irrespective  of  the  presence 
or  absence  of  a  leucocytosis. 


652 


ANEMIA,    SECONDARY    (DA  COSTA). 


The  bone-marrow  in  a  severe  case 
of  anemia  undergoes  a  moderate  de- 
gree of  softening  and  acquires  a  some- 
what reddish  hue,  the  attendant  his- 
tological changes  of  this  transforma- 
tion consisting  of  a  hyperplasia  of  the 
lymphoid  elements  and  a  diminution 
in  the  number  of  fat-cells,  which  are 
replaced  by  marrow-cells  or  myelo- 
cytes charged  with  neutrophilic  and 
eosinophilic  granulations.  Nucleated 
erythrocytes  or  erythroblasts,  chiefly 
of  the  normoblastic  type,  are  numer- 
ous when  active  powers  of  hemo- 
genesis  persist.  H.  C.  Bunting's 
studies  of  the  blood  and  bone-marrow 
in  rabbits  rendered  anemic  by  the 
injection  of  hemolytic  poisons  has 
thrown  a  clear  light  upon  the  dif- 
ference between  the  marrow  changes 
incident  to  anemias  of  different 
grades  of  development.  This  investi- 
gator showed  that  hemolytic  anemia 
excited  by  saponin  is  associated  with 
more  or  less  effectual  depletion  of 
the  marrow-centers  wherein  prolifera- 
tion of  the  blood-cells  takes  place, 
and  with  fragmentation  and  other 
degenerative  changes  in  the  other 
marrow-cells,  the  blood-picture  be- 
traying this  grave  myeloid  lesion 
virtually  corresponding  to  that  of 
true  pernicious  anemia  in  man.  In 
contrast  to  these  findings,  posthemor- 
rhagic anemia,  despite  the  presence 
of  characteristic  changes  in  the  pe- 
ripheral blood,  does  not  affect  the  in- 
tegrity of  erythrogenic  and  leucogenic 
centers  of  the  marrow.  Furthermore, 
it  would  appear  that  in  some  in- 
stances the  proliferating  centers  of 
the  marrow  become  quite  replaced 
by  scar  tissue,  in '  which  event  the 
hematopoietic  function,  now  impos- 
sible for  the  crippled  marrow  to 
carry  on,  is  undertaken  by  the  spleen. 


There  is  a  well-established  relation 
of  diffuse  cord  degeneration  with  per- 
nicious anemia.  It  seems  highly  prob- 
able that  the  hemolysis  and  the  cord 
changes  are  due  to  the  same  lesion. 
While  the  source  of  the  latter  is  un- 
known, the  fact  that  gastrointestinal 
disturbance  is  so  common  in  the  disease 
would  lead  one  to  suppose  that  it  is  of 
intestinal  origin.  The  diffuse  degener- 
ations of  the  spinal  cord  which  occur 
in  conditions  without  pernicious  anemia 
do  not  appear  to  differ  essentially  from 
those  of  pernicious  anemia.  It  is  pos- 
sible that  a  common  blood-circulating 
poison  exists  which  may  expend  its 
force  upon  the  blood  in  one  individual, 
upon  the  nervous  apparatus  in  another, 
and  coincidently  upon  the  blood  and 
spinal  cord  in  others.  F.  Billings 
(Boston  Med.  and  Surg.  Jour.,  Sept. 
4,  1902). 

Examination  of  a  large  number  of 
cases  proves  that  the  changes  in  the 
cord  are  in  a  sense  mechanically 
located,  that  is,  those  portions  of  the 
cord  less  well  supplied  with  blood  are 
the  first  to  suffer.  The  posterior  half 
containing  the  sensory  and  motor  con- 
duction paths  is,  therefore,  more  fre- 
quently involved,  but  the  gray  matter, 
or  even  the  anterior  horns,  may  be 
affected.  The  symptoms  are  variable 
and  obscure,  and  may  be  overlooked ; 
but  in  some  cases  they  are  prominent 
enough  to  lead  to  the  diagnosis  of 
tabes,  spastic  paraplegia,  or  a  neuritis. 
Symptoms  of  any  of  these  conditions 
may  be  present,  depending  upon  the 
portion  of  the  cord  involved,  x^lmost 
invariably  these  patients  complain  prin- 
cipally of  disturbances  of  sensation. 
They  describe  numbness,  tingling,  and 
formication,  usually  in  the  lower  ex- 
tremities, sometimes  in  all  four.  The 
sensation  may  be  that  of  pressure  from 
within  or  without;  some  feel  as  if  tight 
bandages  were  drawn  around  their 
limbs.  With  these  sensations  there  may 
be  a  reduction  in  the  reflexes,  causing 
a  suspicion  of  neuritis.  There  is  usu- 
ally very  little  atrophy,  and  the  elec- 
trical reactions  are  normal ;  but  some- 
times the  gray  matter  of  the  cord  is 
involved,    and   both    atrophy    and    elec- 


ANEMIA,    SECONDARY    (DA  COSTA). 


653 


trical  changes  may  be  present  in  the 
terniinal  stages.  Paralyses,,  loss  of 
sphinctcric  action,  and  marked  mental 
disturbances  have  been  observed,  and 
severe  cases  usually  perish  miserably. 
A.  Church  (N.  Y.  Med.  Jour.,  July  26, 
1902) . 

The  visceral  chanp^es  to  be  noted  in 
cases  of  chronic  secondary  anemia  in- 
clude granular  degeneration  of  the 
liver,  kidneys,  and  heart,  and,  in  some 
instances,  fatty  changes  in  these 
organs.  These  lesions  depend  more 
upon  concomitant  disturbances,  such 
as  toxemia  and  nutritional  faults, 
than  upon  the  efifect  of  the  anemia 
per  sc,  and  it  seems  within  the  bounds 
of  reason  to  assume  that  they  arise 
in  part  from  an  undue  visceral  activ- 
ity excited  b}-  the  organism's  attempt 
to  maintain  a  normal  process  of 
oxidation. 

Two  cases  of  primary  chronic  anemia 
in  men  of  62  and  68.  In  this  type  the 
anemia  is  moderate  in  degree,  and  is 
accompanied  by  enlargement  of  the 
spleen,  slight  poikilocytosis  of  the  red 
corpuscles,  and  excessive  leucopenia,  as 
low  as  660,  without  essential  marrow 
elements.  The  affection  progresses  to 
a  fatal  termination  in  about  six  months, 
with  variable  moderate  or  high  fever 
of  a  continuous  or  intermittent  type. 
The  signs  of  a  hemorrhagic  diathesis 
do  not  appear  until  late,  and  are  not 
severe.  The  bone-marrow  becomes 
completely  atrophied  or  shows  signs 
of  acute  degeneration.  The  blood  find- 
ings are  not  those  of  pernicious  anemia, 
especially  the  leucopenia.  The  symp- 
toms resembled  those  of  what  has 
been  called  "aplastic  anemia,"  but  the 
writer  thinks  that  the  findings  in  the 
bone-marrow  were  of  a  different  nature. 
O.  Kurpjuwelt  (Deut.  Archiv  f.  klin. 
Med.,  Bd.  Ixxxii,  Nu.  5-6,  1905). 

The  liver,  the  spleen,  and  frequently 
the  lymph-nodes  assume  a  fetal  type 
in  grave  or  pernicious  anemias  as  far 
as  their  cellular  character  is  concerned. 
Erythroblastic  cells  and  newly   formed 


leucocytes  appear  in  them,  while  the 
blood-making  organ  of  the  adult,  the 
bone-marrow,  shows  likewise  a  picture 
of  greatly  increased  activity.  The 
writer,  together  with  Heinecke,  has  in- 
terpreted these  phenomena  as  repara- 
tive in  nature  in  opposition  to  another 
conception  of  the  findings  which  seeks 
to  interpret  them  as  the  primary  result 
of  some  unknown  harmful  agent.  Von 
Domarus  has  greatly  strengthened  the 
standpoint  maintained  by  the  writer  by 
producing  experimental  anemias  in 
animals  and  showing  that  the  changes 
in  the  blood-making  organs  of  intra- 
uterine as  well  as  of  extrauterine  life 
were  similar  in  these  animals  to  those 
observed  in  patients  with  pernicious 
anemia.  Meyer  (Miinch.  med.  Woch., 
June  2,  1908). 

SYMPTOMATOLOGY.  —  Pallor, 
the  suggestive  hallmark  of  all  ane- 
mias, is  usually  well  marked  in  the 
secondary  type  of  this  affection,  and 
the  subject's  skin,  mucosa,  and  nails 
may  become  so  blanched  as  to  ap- 
pear almost  colorless.  In  other  in- 
stances, the  loss  of  color  is  much 
more  moderate,  and  in  still  others 
the  actual  pallor  is  more  or  less  ob- 
scured by  a  yellowish  or  muddy  or 
icteroid  staining  of  the  integument. 
In  passing,  it  may  be  remarked  that 
pallor  of  itself  does  not  justify  a 
diagnosis  of  anemia,  for  many  persons 
with  unnaturally  pale  faces  have  a 
perfectly  normal  blood-picture,  in 
view  of  which  the  blood  examination 
must  invariably  be  the  court  of  final 
appeal. 

Pallor  is  often  confounded  with 
anemia.  The  blood  should  be  examined 
in  all  cases  of  pallor,  since  many  con- 
ditions may  give  rise  to  ochriasis,  viz. : 
The  emotion  experienced  by  some  pa- 
tients when  undergoing  examination  at 
the  hands  of  the  physician,  their  tem- 
porary pallor  subsiding  as  they  become 
more  reassured ;  insufficient  outdoor 
air  and  exercise,  giving  rise  to  insuffi- 


654 


ANEMIA,    SECONDARY    (DA  COSTA). 


cient  peripheral  circulation  though  the 
quantity  and  quality  of  the  blood  may 
be  normal;  ill-defined  myxedema,  in 
which  the  blood-vessels  are  narrowed 
by  pressure  upon  them  from  the  gela- 
tiniform  edema  and  sclerosis  of  the 
subcutaneous  tissues.  The  resulting 
pallor  may  give  rise  to  a  faulty  diag- 
nosis of  anemia.  Though  pallor  may 
be  due  to  the  mechanical  influences 
mentioned,  thyroid  insufficiency  may,  in 
itself,  produce  anemia;  hence,  the  im- 
portance of  blood  examination ;  the 
scrofulous  or  lymphatic  diathesis,  with 
the  thickening  of  the  integument  upon 
face  and  extremities,  may  produce  pal- 
lor for  the  same  mechanical  reasons 
obtaining  in  myxedema,  though  exam- 
ination may  show  the  blood  to  be  nor- 
mal; aortic  insufficiency  with  periph- 
eral vasoconstriction  gives  rise  to  a 
pallor  which  at  first  sight  suggests 
anemia;  peripheral  vasoconstriction  is, 
in  the  majority  of  cases,  responsible  for 
the  pallor  seen  in  Bright's  disease, 
though  anemia  secondary  to  the  ne- 
phritis may  occur.  Finally,  in  a  certain 
proportion  of  cases,  a  condition  of 
oligohemia  may  be  responsible  for  pal- 
lor, the  quality  of  the  blood  being  nor- 
mal, though  the  quantity  is  insufficient 
to  thoroughly  irrigate  the  skin.  M. 
Labbe  (Gaz.  med.  Nantes,  April  11, 
1903). 

Aside  from  pallor,  the  most  con- 
spicuous symptom  groups  in  anemia 
are  attributable  to  disturbances  of 
the  cardiovascular,  the  gastrointesti- 
nal, and  the  nervous  systems.  Of  the 
circulatory  symptoms,  dyspnea,  car- 
diac palpitation,  and  dropsical  swell- 
ing of  the  ankles  and  legs  are  likely 
to  prove  sources  of  great  distress  to 
the  patient,  while  the  discovery  of 
hemic  murmurs  at  the  base  of  the 
heart  and  of  a  venous  hum  at  the  root 
of  the  neck  affords  findings  of  the 
utmost  pertinence.  These  anemic 
murmurs,  generally  situated  at  or 
near  the  pulmonic  orifice,  are  almost 
invariably    systolic    in    time    and    re- 


stricted to  the  precordial  area  or  to 
its  immediate  vicinity.  They  are 
sometimes  associated  with  a  percepti- 
ble increase  in  the  size  of  the  cardiac 
outline,  indicative  of  dilatation  of  the 
heart  from  defective  myocardial  nu- 
trition, overstrain,  and,  exceptionally, 
fatty  degeneration. 

Alterations  in  the  size  of  the  heart  in 
anemic  subjects.  Dilatation  is  com- 
monly met  with,  and  sometimes,  es- 
pecially in  chlorosis,  elevation  of  the 
diaphragm  displaces  the  heart  upward 
and  an  apparent  dilatation  is  found. 
Anemic  dilatation  is  to  be  considered 
true  idiopathic  dilatation  resulting  from 
overstrain.  None  of  the  usual  symp- 
toms are  present;  gastralgia  alone  is 
complained  of.  Wybauw  (Jour.  med. 
de  Brux.,  Mar.  15,  1900). 

There  is  nothing  pathognomonic 
about  the  anemic  murmurs  which  dis- 
tinguishes them  from  the  organic  heart 
bruits.  The  most  trustworthy  charac- 
teristics of  these  murmurs  are  their 
slight  tendency  to  transmission,  their 
appearance  during  the  systole,  as  a  rule, 
over  the  area  of  the  pulmonary  artery, 
their  variability  and  their  increase  in 
intensity  in  the  standing  posture  and 
decrease  in  the  recumbent  position.  As 
a  rule,  the  general  examination  of  the 
patient  determines  whether  we  have  to 
deal  with  an  anemic  or  an  organic  mur- 
mur. Orlofsky  (Roussky  Vratch,  June 
7,  1903). 

The  distinct  positive  venous  pulse  ob- 
served in  endocarditis  is  not  an  uncom- 
mon symptom  of  anemia  and  is  due  to 
a  relative  muscular  insufficiency  of  the 
tricuspid  orifice.  The  cause  is  the  same 
as  that  of  the  mitral  insufficiency  so 
common  in  chlorosis.  In  order  to  make 
sure  of  the  functional  character  of  the 
condition,  it  is  important  to  bear  in 
mind  that  a  relative  tricuspid  insuffi- 
ciency in  anemia  develops  at  the  same 
time  as  the  mitral  insufficiency,  while 
in  endocarditis  the  tricuspid  lesion  usu- 
ally develops  long  after  the  mitral. 
Besides,  disturbances  of  compensation 
are  usually  absent.  Von  Leube  (Zeit. 
f.  klin.  Med.,  Bd.  Ivii,  Nu.  3-4,  1905). 


ANEMIA,    SECONDARY    (DA  COSTA). 


655 


The  foregoing  symptoms,  which 
are  prominent  only  in  severe  anemias, 
promptly  vanish  as  the  normal  compo- 
sition of  the  blood  is  regained,  and  fre- 
quently in  such  cases  the  pulse  is  in- 
ordinately rapid,  of  low  tension,  and 
subject  to  arhythmic  disturbances, 
while  occasionally  the  abrupt,  jerky  beat 
of  the  Corrigan  pulse  is  superficially 
imitated. 

Of  the  symptoms  referable  to  the 
■  gastrointestinal  tract,  anorexia,  pyrosis, 
abdominal  distention,  sensitiveness,  and 
unrest,  nausea,  and  constipation  may 
attract  attention.  In  the  average  case 
of  secondary  anemia  the  motor  powers 
of  the  stomach  are  unaltered,  and  the 
secretion  of  hydrochloric  acid  remains 
normal  or  is  even  increased.  On  the 
other  hand,  there  is  a  decided  tendency 
toward  weakening  the  intestinal  motor 
function,  although  the  juices  of  the  gut 
flow  naturally  (Boas,  v.  Noorden). 

Ulcers  in  the  throat  may  be  due  to 
anemia  or  lowered  vitality.     The  writer 
has  seen  3  cases;  all  in  young  women. 
The  ulcer  is  round,  small,  with  scanty 
secretion.      There    was    no    history    of 
either   tuberculosis    or    syphilis    and   no 
swelling  of  the  glands.     Pohly    (N.  Y. 
Med.  Jour.,  x\ug.  27,  1910). 
Of  the  various  nervous  disturbances, 
headache,    vertigo,    syncope,    insomnia, 
phosphenes,  muscse  volitantes,  and  tin- 
nitus   aurium    are    familiar    examples. 
Moderate,  irregular  fever  is  occasion- 
ally observed  as  a  consequence  of  nerv- 
ous  factors   and   as   a   sign   of   septic 
processes.     Most   anemics,    particularly 
those  of  chronic  character,  complain  of 
unnatural     fatigue,    both    mental    and 
muscular,  and  in  severe  cases  the  pa- 
tient may  be  incapable  of  sustained  in- 
tellectual effort,  exhibits  curious  mental 
caprices  and  irritability,  and  develops  a 
myasthenia  amounting  almost  to  com- 
plete debility. 


Menorrhagia  as   a   symptom   of   ane~ 
mia   must   be    regarded  as   a   result   of 
muscular    inadequacy,   the   cause   of    so 
many   varieties   of   uterine   hemorrhage. 
The  uterine  muscle,  by  compressing  the 
uterine  blood-vessels,  controls  the  blood- 
supply  of  the  organ  and  the  escape  of 
blood   from  its  lining  membrane.     Any 
defect    in    uterine    wall    muscularity,    as 
compared   with   vascularity,   permits   of 
pathological    uterine    hemorrhage.      For 
months  before  puberty  the  uterine  mus- 
cle grows  in  bulk  and  the  uterine  vessels 
increase  in  size  and  number.    When  the 
first  menstruation  occurs,  if  the  uterine 
muscle  be  well  developed,  as  is  usually 
the  case,  no  undue  hemorrhage  appears, 
but  if  muscle  growth  lags  behind  vessel 
development  muscular   inadequacy  per- 
mits   prolonged    and    profuse    bleeding. 
Puberty  menorrhagia  usually  disappears 
in  a  few  months,  since  muscle  growth 
increases    and    gains    control    over    the 
blood-vessels.     W.  E.  Fothergill   (Med. 
Chronicle,  July,  1905). 

Six  cases  of  anemia  of  the  central 
nervous  system,  resulting  in  sclerosis 
of  the  cord.  The  onset  of  the  disease 
is  gradual.  The  symptoms  are  very 
variable,  as  are  the  changes  in  the  spinal 
cord.  Sometimes  the  pos'.erior  columns 
are  involved;  sometimes  the  lateral 
tracts  are  added;  again,  there  is  a  dif- 
fuse sclerosis  of  the  entire  cord.  Pares- 
thesia and  ataxia  may  persist  for  years 
with  few  changes  in  the  cord,  or  the 
intensity  of  the  alterations  may  be  much 
greater  than  the  clinical  symptoms.  The 
mental  state  may  be  dull  and  inattentive, 
and  there  may  be  various  muscular  pal- 
sies of  eye  m.uscles  or  face.  Leopold 
(Med.  Rec,  Mar.  5,  1910). 

The  blood-picture  of  secondary 
anemia  is  in  no  wnse  distinctive,  as 
already  pointed  out  in  the  remarks 
on  the  pathology  of  this  aftection. 
Usually  there  is  a  moderate  and 
roughly  parallel  loss  of  hemoglobin 
and  erythroc3-tes,  the  former  being 
diminished  approximately  45  per 
cent,  and  the  latter  30  per  cent,  below 
the  normal  standard,  in  the  case  of 


656 


ANEMIA,    SECONDARY    (DA  COSTA). 


average  severity.  The  stained  film 
generally  shows  nothing  more  than 
simple  pallor  of  the  erythrocytes 
with,  perhaps,  a  few  misshapen  cells 
and  some  tendency  toward  irregu- 
larity in  their  diameter  measure- 
ments. Normoblasts  and  erythrocytes 
with  stroma  degeneration  are  met 
with  only  in  anemias  of  great  inten- 
sity, characterized  by  excessive  de- 
struction of  the  cells,  and  under  such 
conditions  an  occasional  megaloblast, 
indicating  a  fetal  reversion  of  the 
marrow,  may  enter  the  blood-stream. 
Leucocytosis,  developing  under  the 
circumstances  referred  to  in  a  pre- 
ceding paragraph,  means  stimulation 
of  the  marrow's  functional  activity, 
the  exhibition  of  which  is  regulated 
largely  by  the  nature  of  the  excit- 
ing cause  and  by  the  individual  pe- 
culiarities dominant  in  the  case  under 
consideration.  The  coagulation-time 
(hcmatopexis)  of  the  blood  is  shortened 
in  close  relation  with  the  degree  of 
existing  anemia. 

Case  of  ankylostomiasis  in  which  there 
were  hemorrhages  into  the  retina.  The 
patients  did  not  complain  of  their  eyes, 
and  yet  hemorrhages  were  found  in  the 
retina.  They  probably  constitute  a  con- 
stant symptom  in  severe  forms  of  ane- 
mia due  to  ankylostoma.  These  hemor- 
rhages appear  in  the  form  of  round 
spots,  bands,  and  semilunar  marks  (pre- 
retinal  hemorrhages),  and  are  chiefly 
found  in  the  neighborhood  of  the  pos- 
terior pole  of  the  ej^e.  Their  presence 
has  an  unquestionable  influence  on  the 
prognosis.  They  take  place  by  diapede- 
sis,  are  absorbent  without  leaving  any 
traces,  and  do  not  give  rise  to  any  in- 
flammatory symptoms.  They  occur 
chiefly  in  the  layer  of  nerve-fibers,  but 
may  penetrate  to  the  outer  layers  of  the 
retina,  even  to  the  external  limiting 
membrane.  Changes  in  the  smaller  ret- 
inal vessels  consist  in  swelling  of  the 
nuclei  of  the  endothelial  cells.  Tchemo- 
lossoff  (Roussky  Vratch,  Nov.  29, 1903). 


It  was  at  first  believed  that  in  severe 
anemia  the  relative  and  absolute  con- 
sumption of  O2  and  production  of  CO2 
diminished.  Later  it  was  shown  (Kraus) 
that  the  gaseous  metabolism  tended,  on 
the  whole,  to  be  increased  above  the 
normal  rather  than  diminished  in  severe 
anemia,  and  was  capable  of  still  further 
increase  on  exertion.  Patients  with  only 
10  per  cent,  of  the  normal  amount  of 
hemoglobin  are  not  rarely  met  with,  and 
Xageli  has  described  one  with  only  7 
per  cent. ;  the  authors  set  out  to  investi- 
gate how  this  drop  in  hemoglobin  is 
compensated.  In  the  first  place,  they 
remark  that  no  other  substance  in  the 
blood,  besides  the  hemoglobin,  can  act 
as  an  oxygen  carrier;  further,  in  all 
anemias,  except,  perhaps,  chlorosis,  the 
total  volume  of  the  blood  is  lessened. 
Hiifner  has  always  argued  that  the 
02-capacity  of   hemoglobin   is   constant, 

1  gram  of  Hb  taking  up  1.34  c.c.  O2," 
but  Bohr  and  many  other  writers  bring 
forward  good  reasons  for  supposing 
that  its  specific  02-capacity  is  variable — 
at  any  rate  to  the  extent  of  20  per  cent. 
— and  that  hemoglobin  is  not  a  single  or 
uniform  chemical  compound.  Thus 
Kraus  found  that  1  gram  Hb  could  take 
up  from  0.9  to  1.97  c.c.  Oo.  Mohr 
found  the  specific  02-capacity  to  rise 
from  1.26  to  2.0  c.c.  O2  per  gram  of 
Hb,  in  the  course  of  six  days  and  after 
two  bleedings,  and  so  was  led  to  regard 
the  variability  of  the  02-capacity  of  the 
hemoglobin  as  a  compensatory  protect- 
ive mechanism  for  use  in  anemia.  Sev- 
eral observers  have  found  the  Oo-capaci- 
ties  (0.8  to  1.0  c.c  O2  per  gram  of 
Hb)  in  patients  with  polycythemia  ru- 
bra, and  these  observations  have  been 
used  to  explain  the  polycythemia  noted 
in  that  condition.  The  authors  believe 
that  the  02-capacity  of  blood  varies  with 
its  coloration  (=Hb-content)  exactly, 
as  Haldane  stated,  and  they  find  this  to  be 
the  case  in  polycythemia  and  in  anemia. 
They  were  unable  to  find  any  increase 
in  the  Oo-capacity  of  the  Hb  in  anemic 
patients;  but  in  a  number  of  these  the 
percentage  of  oxygen  used  up  in  the 
capillaries  was  above  the  normal — ven- 
ous  blood    is    normally    saturated   with 

02  to  the  extent  of  about  60  to  75  per 


ANEMIA,    SECONDARY    (DA  COSTA). 


657 


cent.,  but  in  severe  anemia  perhaps  only 
to  the  extent  of  15  to  50  per  cent.  They 
agree  with  Mohr  that  this  increase  in 
the  percentage  of  oxygen  consumed  in 
the  tissues  is  an  important  compensatory 
mechanism  in  anemia.  But  it  is  not  the 
only,  nor  indeed  even  the  most  impor- 
tant, compensatory  mechanism  ;  they  be- 
lieve that  increased  speed  in  the  flow  of 
blood  through  the  vessels  must  be  the 
most  important  of  these.  In  two  pa- 
tients with  polycythemia  rubra  they 
found  no  diminution  in  the  maximum 
Oo-capacity  of  the  hemoglobin,  nor  did 
the  patients  exhibit  any  increase  in  their 
tissue  respiration  such  as  Senator  be- 
lieved to  obtain  in  this  condition.  Mora- 
witz  and  Rohmer  (Deut.  Arch.  f.  klin. 
Med.,  Bd.  xciv,  S.  529,  1908;  Med. 
Chronicle,  Nov.,  1909). 

DIAGNOSIS.— The  diagnosis  of 
secondary  anemia  invariably  must  be 
based  upon  a  suggestive  blood  picture 
plus  the  discovery  of  some  factor 
responsible  therefor.  Given  a  blood 
poor  in  hemoglobin  and  erythrocytes 
in  an  individual  suffering,  for  instance, 
with  sepsis  or  gastric  cancer  or  rheu- 
matic fever,  the  diagnosis  Can  tax  no 
one's  intelligence.  But  given  an  ob- 
scure etiological  factor  in  an  anemic 
person,  one  must  carefully  interrogate 
through  a  long  list  of  potential  causes 
of  blood  impoverishment  in  order  to 
detect  a  satisfactory  cause.  The  dif- 
ferential diagnosis  of  secondary  ane- 
mia includes  the  consideration  of 
pseudoanemia,  chlorosis,  pernicious 
anemia,  splenic  anemia,  leukemia, 
chloroma,  and  Hodgkin's  disease. 

We  must  not  judge  entirely  of  the 
presence  or  absence  of  anemia  by  the 
volume  and  condition  of  the  blood 
alone,  but  also  by  the  function  of  the 
tissues  which  are  dependent  on  the  blood 
for  their  well-being.  Thus  85  per  cent, 
of  hemoglobin,  with  4,000,000  red  cor- 
puscles, may  be  normal  for  one  indi- 
vidual in  apparently  perfect  health,  and 
yet  another  person  of  the  same  body- 
weight  with  this  condition   may   sufifer 


to  a  considerable  degree  from  anemia. 
Brooks  (Med.  News,  Oct.  21,  1905). 

Pseudoanemia  versus  true  anemia  is 
a  differentiation  constantly  to  be 
borne  in  mind  in  examining  a  patient 
for  the  first  time.  Spurious  anemia, 
which,  of  course,  shows  a  normal 
blood  report,  is  characterized  by  un- 
natural pallor  of  the  skin  and  mucous 
surfaces,  probably  of  hereditary  origin 
and  explainable  on  the  grounds  of  a 
deficiency  of  skin  pigment  and  abnor- 
mal constriction  of  the  superficial 
capillary  network.  Apart  from  pallor, 
the  aff'ection  is  quite  symptomless. 
In  this  connection  may  be  mentioned 
an  angiospastic  type  of  pseudoanemia, 
recognized  by  the  abrupt  appearance 
of  attacks  of  transient  grayish  pallor 
induced  by  emotion,  fatigue,  exposure 
to  cold,  and  similar  vasomotor  stimuli. 

Chlorosis^  though  its  blood  picture 
may  be  precisely  counterfeited  by 
certain  forms  of  secondary,  anemia 
(such  as  Chlorosis,  q.v.),  is  readily  dis- 
tinguished from  the  latter  by  its  oc- 
currence exclusively  in  girls  and  in 
young  women  who  exhibit,  with  pass- 
able fidelity,  a  varied  train  of  un- 
mistakable chlorotic  stigmata — green- 
ish pallor,  menstrual  disturbances, 
perverted  appetite,  indigestion,  con- 
stipation, slight  enlargement  of  the 
thyroid  gland,  and  many  symptoms 
referable  to  functional  neuroses. 

Pernicious  anemia  in  its  typical  form 
gives  rise  to  three  most  pertinent 
blood  changes :  extreme  oligocythe- 
mia combined  with  a  disproportion- 
ately slighter  oligochromemia ;  the 
presence  of  numerous  erythroblasts, 
of  which  cells  those  of  a  megaloblastic 
tj^pe  predominate ;  and  many  de- 
formed and  otherwise  degenerate 
erythrocytes,  notably  megalocytes 
and  basophilic  corpuscles.     The  first 


1—42 


658 


ANEMIA,    SECONDARY    (DA  COSTA). 


detail  of  this  blood-picture  means 
that  the  hemoglobin  content  of  the 
erythrocytes  {color  index)  is  unnat- 
urally high ;  the  second  indicates 
active  compensatory  hemogenesis  and 
fetal  reversion  of  the  bone-marrow, 
and  the  last  points  to  the  manufac- 
ture by  the  marrow  of  numerous 
faultily  formed,  functionless  erythro- 
cytes, of  little  or  no  use  as  oxygen 
carriers.  Leucopenia,  relative  lym- 
phocytosis, and  a  moderate  degree  of 
myelocytosis  are  among  the  other 
hematological  features  of  this  disease. 
In  addition  to  these  findings,  it  must 
be  recalled  that  true  pernicious  ane- 
mia arises  insidiously,  is  entirely  un- 
connected vi^ith  any  tangible  causal 
factor,  and  invariably  progresses 
steadily,  perhaps  with  temporary 
periods  of  remission,  to  a  fatal  ter- 
mination. An  aplastic  type  of  per- 
nicious anemia  has  been  described,  in 
which,  owing  to  extraordinary  atro- 
phy of  the  bone-marrow,  there  arises 
an  intense  oligocythemia  and  oligo- 
chromemia  with  but  trifling  evidence 
of  structural  degeneration  and  nuclea- 
tion  of  the  red  corpuscles.  In  at- 
tempting the  antemortem  differentia- 
tion of  aplastic  anemia  and  anemia  of 
the  symptomatic  variety  (which  at- 
tempt must  needs  frequently  be  con- 
jectural), attention  should  be  paid 
especially  to  these  hematological  pe- 
culiarities of  the  first-named  disease: 
relatively  low  color  index;  absence 
of  erythroblasts  of  both  types — 
normoblasts  and  megaloblasts ;  scar- 
city of  cells  showing  stroma  defects 
and  -anomalies  of  shape  and  size,  and 
extreme  lymphocytic  leucopenia.  It 
is  also  helpful  to  remember  that 
aplastic  anemia  is  prone  to  affect 
young  women,  is  commonly  asso- 
ciated   with    severe   hemorrhagic    phe- 


nomena, and,  arising  from  no  apparent 
cause,  pursues  a  fatal  course  of  short 
duration,  unbroken  by  periods  of 
remission. 

Splenic  anemia,  a  rare  and  somewhat 
questionable  clinical  entity,  causes  a 
blood  deterioration  in  no  wise  different 
from  that  accompanying  an  ordinary 
symptomatic  anemia  with  leucopenia. 
But  in  splenic  anemia  there  is  an  idio- 
pathic splenomegaly  without  enlarge- 
ment of  the  lymphatic  glands,  and,  in 
the  later  stages  of  the  disease,  biliary 
hepatic  cirrhosis,  jaundice,  and  ascites 
supervene,  to  complete  the  symptom 
group  sometimes  spoken  of  as  Banti's 
disease.  Disturbances  due  to  severe 
anemia  and  to  the  pressure  of  an  enor- 
mous spleen  are  generally  conspicuous, 
and  the  disease  is  likely  to  develop 
insidiously,  drags  along  for  several 
years  from  bad  to  worse,  and  eventually 
kills. 

Leukemia  is  easily  distinguished  from 
secondary  anemia  by  means  of  its  dis- 
tinctive blood  picture,  as  well  as  by 
certain  objective  symptoms.  In  the 
myelogenous  form  the  combination  of 
a  high  leucocyte  count  and  excessive 
numbers  of  myelocytes  (myelemia)  is 
conclusive,  and  in  such  cases  the  spleen 
is  generally  enormous ;  in  the  lymphatic 
variety  the  detection  of  a  high  absolute 
and  relative  lymphocytosis  (lymphemia) 
is  equally  convincing,  and  here  it  is  the 
rule  to  find  great  hyperplasia  of  the 
lymphatic  glands. 

Chloroma  may  account  for  an  anemia 
identical  with  that  of  the  secondary 
type,  and  it  may  also  produce  a  blood 
picture  closely  comparable  to  that  of 
lymphatic  leukemia.  In  the  former 
instance  the  low  hemoglobin  and  eryth- 
rocyte values  are  accompanied  by  a 
relative  increase  in  the  number  of 
lymphocytes,  though  the  total  leucocyte 


ANEMIA,    SECONDARY    (DA  COSTA). 


659 


count  does  not  exceed  normal,  while 
in  the  latter  the  blood  shows  great 
anemia  with  decided  lymphemia.  This 
being  tlie  case,  one  must  recognize 
chloroma  not  by  any  distinctive  blood 
formula,  but  by  the  chloromatous 
symptom-complex,  made  up  of  exoph- 
thalmos, deafness,  severe  orbital  pain, 
elastic  swellings  in  the  orbital  and  tem- 
poral regions,  and  the  formation  of 
metastatic  "green  tumors"  in  the  peri- 
osteal structures. 

In  Hodgkin's  disease,  which  in  time 
gives  rise  to  high-grade  secondary 
anemia,  the  existence  of  a  progressive 
glandular  hyperplasia  in  the  neck, 
axilla,  and  groin  is  conclusive  evidence, 
apart  from  the  presence  of  pressure 
symptoms,  irregular  fever,  cutaneous 
bronzing,  asthenia,  and  extraordinary 
emaciation,  which  together  spell  this 
malignant  affection. 

PROGNOSIS.— It  is  scarcely  nec- 
essary to  state  that  the  prognosis  in  a 
given  case  of  secondary  anemia  must 
depend  upon  the  circumstances  prevail- 
ing in  the  instance  in  question,  the 
character,  duration,  and  curability  of 
the  primary  lesion  being  the  decisive 
determining  points  of  the  forecast. 
The  outlook  in  gastric  cancer,  for  ex- 
ample, is  very  dift'erent  from  that  in 
simple  inanition  or  in  one  of  the  milder 
infectious  diseases.  On  the  whole, 
secondary  anemia  is  a  symptom  that  is 
promptly  amenable  to  intelligent  treat- 
ment, in  strong  contrast  to  which  fact 
•is  the  utter  hopelessness  of  accomplish- 
ing a  permanent  cure  in  those  deadly 
primary  diseases  of  the  blood,  perni- 
cious anemia  and  the  leukemias. 

TREATMENT.— Iron  and  arsenic, 
nutritious  food,  and  correct  hygiene 
will  cure  secondary  anemia — provided 
that  the  essential  cause  of  this  symptom 
be  removed.     It  is  just  as  important  to 


attend  to  a  mass  of  bleeding  piles  or  to 
treat  an  albuminuria  in  an  anemic  per- 
son as  it  is  to  prescribe  hematinics,  and, 
by  the  same  token,  it  is  equally  impor- 
tant to  outline  a  regimen  in  which  an 
out-of-door  life,  ample  sleep,  and  ra- 
tional personal  hygiene  are  items  of 
strict  observance. 

The  percentage  of  hemoglobin  in  in- 
fancy is  below  55  at  birth  and  not  rising 
above  70  during  the  period  properly- 
so-called  of  infancy.  The  number  of 
red  corpuscles  varies  between  5,500,000 
and  6,000,000.  This  low  hemoglobin  per- 
centage is  presumably  due  to  an  insuffi- 
cient supply  of  iron  in  its  food  and  the 
lack  of  sufficient  reserve  of  iron  in  the 
liver  at  birth.  It  is  probable  that  true 
chlorosis  never  occurs  in  infants  as  a 
disease,  but  it  is  a  fact  that  the  chlorotic 
type  of  blood  is  very  common  at  this 
age.  Iron  is,  therefore,  specially  indi- 
cated, but  it  is  difficult  to  get  infants 
to  take  iron  by  the  mouth,  and  it  is  very 
liable,  moreover,  to  disturb  the  diges- 
tion. It  is  desirable,  therefore,  to  give 
it  some  other  way,  and  infants  take  it 
subcutaneously  without  injury.  A  very 
serviceable  form  for  subcutaneous  use 
is  the  aqueous  solution  of  the  citrate. 
This  can  be  put  up  in  pearls,  each  one 
containing  a  single  dose,  in  which  form 
it  remains  sterile  indefinitely.  It  is  ab- 
solutely non-irritating,  and  never  causes 
abscess  or  induration  if  properly  given, 
though  it  is  somewhat  painful.  A  glass 
syringe  with  an  asbestos  packing,  which 
can  be  sterilized,  and  platinum  needle 
that  will  not  corrode  with  the  iron.  The 
average  dose  during  infancy  is  three- 
quarters  of  a  grain  every  other  day. 
He  has  used  this  treatment  in  a  number 
of  cases  in  different  types  of  anemia 
and  with  pretty  satisfactory  results,  even 
in  the  severe  cases.  In  the  mild  cases 
the  improvement  was  very  rapid,  and  the 
writer's  experience  leads  him  to  recom- 
mend the  use  of  iron  in  this  way.  The 
results  are  more  marked  and  more 
quickly  obtained  than  by  oral  adminis- 
tration, and  it  is  much  less  liable  to  dis- 
turb digestion.  It  is  especially  indicated 
in    severe    cases    of    secondary    anemia 


660 


ANEMIA,    SECONDARY    (DA  COSTA). 


with  digestive  disorder  and  in  those  of 
a  sclerotic  type.  J.  L.  Morse  (Jour. 
Amer.  Med.  Assoc,  July,   1910). 

The  form  of  iron  to  be  administered, 
it  is  almost  needless  to  state,  should  be 
readily  absorbable,  and  unlikely  either 
to  upset  digestion  or  to  constipate.  The 
carbonate  of  iron,  in  the  pill  suggested 
by  Blaud,  meets  these  requirements  as 
well  as  any  other  preparation,  and  has 
the  prestige  of  a  long  and  dependable 
clinical  usage.  Excessive  dosage  is  to 
be  avoided,  since  the  use  of  6  or  8 
grains  a  day  will  accomplish  just  as 
satisfactory  results  as  a  much  larger 
amount,  and  will  not  tend  to  disturb  the 
stomach  or  to  constipate.  Ferratin  is  a 
meritorious  chalybeate,  and  is,  if  any- 
thing, even  less  astringent  than  Blaud's 
pill.  Of  the  other  iron  preparations 
sometimes  chosen  for  the  same  reason, 
the  phosphate,  lactate,  and  citrate  all 
enjoy  considerable  vogue. 

The  most  satisfactory  result  is  ob- 
tained with  the  peptomanganate  of 
iron;  it  is  easily  absorbed  by  the  entire 
intestinal  tract  and  evokes  no  concomi- 
tant effects.  In  12  out  of  23  cases  the 
hemoglobin  was  normal  after  fourteen 
days;  in  5  after  three  weeks,  and  in  5 
after  a  month. 

In  acute  anemia  very  good  results 
were  also  obtained  by  this  mode 
of  treatment.  H.  Metall  (Med.  chir. 
Centralbl.,  June,  1902). 

Inorganic  preparations  of  iron  are 
well  utilized  by  the  organism  and  give 
better  and  more  rapid  results  than  or- 
ganic preparations,  the  most  rapid  and 
marked  increase  in  hemoglobin  being 
seen  after  endovenous  injection  of  in- 
organic preparations  of  iron.  Experi- 
mentally there  was  but  slight  difference 
seen  in  the  effects  of  inorganic  and  or- 
ganic preparations  administered  through 
the  digestive  tract,  the  results  obtained 
depending,  in  both  classes,  upon  the 
amount  of  iron  contained  in  them.  F. 
Aporti  and  S.  Aporti  (II  Policlinico, 
Sept-Oct,  1902). 


Subcutaneous  injections  of  the  arsen- 
ate of  iron  valuable  in  anemia.  In  a 
previous  article  the  author  has  shown 
that  injection  of  iron  salts,  if  continued 
for  a  sufficient  length  of  time,  produce 
very  constant  and  trustworthy  results 
in  anemia.  The  arsenate  of  iron  used 
because  the  addition  of  arsenic  improves 
the  action  of  iron.  This  method  of 
.  treatment  used  in  a  large  number  of 
cases  and  considered  the  best  mode  for 
administering  iron.  The  author  em- 
ployed the  solutions  prepared  by  Zam- 
beletti,  in  which  the  arsenate  was  per- 
fectly dissolved.  The  injections  were 
made  preferably  into  the  nates,  with  the 
usual  aseptic  precautions,  by  means  of 
a  syringe  with  a  rather  long  needle. 
The  doses  were  gradually  increased 
until  about  60  or  80  injections  had  been 
given,  when  the  doses  were  gradually 
diminished  again.  Toward  the  end  of 
the  treatment  the  injections  were  alter- 
nated with  the  administration  of  iron, 
arsenic,  and  phosphorus,  as  well  as 
nux  vomica  or  strychnine  by  mouth, 
the  latter  being  continued  for  some  time 
after  the  injections  were  abandoned. 
The  results  obtained  with  this  method 
of  treatment  were  uniformly  satisfac- 
tory in  a  large  number  of  cases.  Nicola 
Fedele  (Gaz.  degli  osped.  e  delle  clin., 
Feb.  1,  1903). 

The  headache  of  anemia  is  due  chiefly 
to  the  deficiency  of  hemoglobin,  and 
consequent  tendency  to  edema,  with  the 
simultaneous  starving  of  the  meninges. 
It  is  usually  frontal,  but  may  be  vertical. 
In  certain  individuals  of  lymphatic  type, 
subject  to  anemia,  chilblains,  and  cold 
extremities,  there  may  be  a  deficiency 
of  calcium  salts  in  the  blood,  and  the 
administration  of  the  calcium  salts  may 
be  of  great  service  in  relieving  the  head- 
aches of  such  patients.  The  lactate 
should  be  given  in  doses  of  15  to  20 
grains,  three  times  a  day.  The  head- 
aches of  the  morning  after  copious  liba- 
tions have  been  ascribed  to  a  lack  of 
calcium  salts  in  the  blood,  these  having 
been  precipitated  by  the  organic  acids 
contained  in  the  wine. 

This  headache  may  be  very  quickly 
removed  by  a  dose  of  20  to  30  grains 
of    calcium    lactate    shaken    up    with    a 


ANEMIA,    SECONDARY    (DA  COSTA). 


661 


little    water.      Wilfrid    Harris     (Prac- 
titioner, July.  1906). 

There  has  been  distinct  progress  in 
the  treatment  of  anemia.  The  first  of 
these  is  the  method  of  direct  trans- 
fusion introduced  bj'  Crile,  whose  ex- 
periments and  results  the  author  con- 
siders a  brilliant  illustration  of  the 
value  of  vivisection  to  humanity.  The 
second  is  the  use  of  colonic  irrigations 
in  pernicious  anemia,  as  recommended 
by  Herter,  and  successfully  employed  by 
Ditmar  and  Hollis.  Herter's  discovery 
that  special  putrefactive  processes  in 
the  intestines  are  due  to  the  prevalence 
of  anaerobic  bacteria,  particularly  the 
Bacillus  capsiflafus  aerogenes,  and  the 
parallelism  of  their  presence  with  the 
symptoms  of  the  disease  suggested  this 
treatment  by  injections,  which  the 
writer  considers  a  valuable  therapeutic 
advance.  The  third  point  touched  on 
in  his  paper  is  the  establishment  of  the 
clinical  value  of  inorganic  iron  in  the 
treatment  of  anemia.  Ingested  iron, 
like  the  carbohydrates,  is  converted  into 
intermediate  organic  compounds  and 
enters  into  the  reser^'e  iron  stored  up 
in  the  body,  which  is  normally  in  excess 
of  the  needs  of  the  system.  S.  J.  Melt- 
zer  (Jour.  Amer.  Med.  Assoc,  Aug.  24, 
1907). 

Employing  the  hemoglobin  contents 
as  an  index  of  the  degree  of  secondary 
anemia,  as  well  as  an  actual  erythroc}-te 
count,  the  writers  found  that  the  hypo- 
dermic use  of  the  citrate  of  iron  in  the 
secondar}'  anemia  of  tuberculosis  per- 
mitted them  to  control  the  anemia  with 
almost  mathematical  precision,  and  that 
it  actually  in  no  single  instance  failed 
to  improve  the  quality  of  the  blood  to 
at  least  some  degree  in  the  256  cases 
in  which  they  had  employed  it.  Over 
70  per  cent,  of  these  cas;s  were  in  the 
advanced  and  far  advanced  classes,  in 
which  the  anemia  is  a  commonly  mani- 
fested phenomenon.  The  measure  was 
uniformly  successful  in  raising  the 
hemoglobin  standard  to  normal  in  all 
cases  in  which  the  patient  might  be 
considered  to  be  doing  well,  or  in 
which  the  status  quo  was  seemingly 
maintained. 


It   is   not   necessary  to   use   a   larger 
dose  of  citrate  of  iron  than  0.05  Gm. 
Others    who    have    used    larger    doses 
have  observed  sudden  vomiting  to  fol- 
low  its  administration.     The   technique 
of  the  method  is  to  employ  the  ordinary 
hypodermic  syringe  and  needle,   select- 
ing   the    buttock    as    the    least    incon- 
venient site  of  injection,  and  giving  an 
injection    daily   until   the   result   is   ob- 
tained.   E.  S.  Bullock  and  L.  S.  Peters 
(Jour.    Amer.    Med.    Assoc,    Oct.    28, 
1911). 
•  Arsenic  is  of  indispensable  value  as 
an    adjunct    to    iron    in    dealing    with 
anemia,    particularly   those    forms    dis- 
tinguished by  relatively  excessive  oligo- 
cythemia, as  in  those  severe  instances 
consequent  to  infectious  and  malignant 
processes.     The  time-honored  Fowler's 
solution  answers  well  in  themajorit}-of 
cases,  but  where  an  idiosyncrasy  exists 
toward  this  preparation,  as  it  frequently 
does,    or    where    it    is    imperative    to 
stimulate     hemogenesis     xevy     rapidly, 
atoxyl  'sodium  anilarsenate)  will  prove 
the  better  form  of  arsenic.     It  should 
always    be    given    hypodermically,    in 
doses  of  from  ^  grain  to  2  grains,  on 
alternate    days,    until    the    patient   has 
received  about  20  grains,   after  which 
the   drug  is   discontinued   for  a  week, 
and   then   readministered   according  to 
the  plan  originally  followed.     Given  in 
this   manner,   one   need   not   fear  that 
lamentable  complication,  optic  neuritis, 
which  has  been  produced  by  the   ill- 
advised  use   of   atoxyl.     Or  arsacetin 
(sodium  acetyl  arsanilate)  may  be  used, 
in    the    same    dose    and   by   the    same 
method    advised    for    atoxjd,    if    it    is 
thought  best  to   employ  an   even  less 
toxic   preparation   of    arsenic.      While 
useful,     manganese,     phosphorus,     red 
bone-marrow,  hemoglobin,  oxygen,  and 
the  cacodylates  are  in  no  sense  adequate 
substitutes  for  iron  and  arsenic  in  the 
treatment  of  anemic  conditions. 


662 


ANEMIA,    SECONDARY    (DA  COSTA). 


Hypodermic  medication  with  iron  and 
arsenic,  together  with  strychnine  and 
the  hypophosphites,  offers  a  prompt 
and  powerful  reconstructive  adjunct  to 
the  pure  air,  good  food,  and  sensible  hy- 
giene that  are  essentials  in  pretubercu- 
lous  conditions.  The  green  ammo- 
niated  iron  citrate  can  be  introduced 
into  the  system,  without  danger,  in  doses 
of  from  }i  to  1^  grains,  while  sodium 
arsenate  is  given  in  doses  of  from  %o 
to  Yso  grain.  The  injections  of  solu- 
tions of  these  drugs  are  given  deeply 
into  the  muscles  of  the  buttocks  or 
back.  Only  slight  pain  attends  the 
procedure,  and  a  general  feeling  of 
well-being  follows  the  treatment.  A 
full  dose  of  the  iron  within  five  minutes 
causes  a  feeling  of  tension  in  the  head, 
tingling  sensations,  and  a  flushing  of 
the  face.  Doses  larger  than  1^^  grains 
may  cause  nausea  or  vomiting.  B.  R. 
Shurly  (Jour.  Amer.  Med.  Assoc,  June 
16,  1907). 

The  anemic  subject  should  eat 
plentifully  of  nutritious,  and,  it  must 
be  insisted,  palatable,  food — red  meats, 
strong  broths,  eggs,  butter,  cream, 
fruits,  and  ferruginous  vegetables  like 
spinach,  asparagus,  lentils,  and  cauli- 
flower. If  the  appetite  flags  it  may 
be  advisable  to  whip  it  up  with  a 
glass  of  stout  or  of  mild  claret  at 
mealtime,  or  by  the  use  of  the  bitter 
tonics,  the  amount  of  food  at  the 
same  time  being  intelligently  re- 
stricted. Indigestion,  if  not  fore- 
stalled by  a  rational  dietary,  must  be 
combated  by  such  useful  remedies 
as  pepsin  and  hydrochloric  acid,  pan- 
creatin  and  diastase,  pawpaw,  char- 
coal, and  bismuth.  It  is  most  neces- 
sary for  the  patient  to  have  a  free 
bowel  movement  each  day,  to  insure 
which,  if  other  measures  fail,  i't  is 
good  practice  to  resort  to  cascara 
sagrada,  phenolphthalein,  singly  or 
combined  with  aloin,  strychnine,  and 
belladonna,    and    supplemented    by    a 


dram  or  two  of  Carlsbad  salts  dissolved 
in  a  tumblerful  of  hot  water,  to  be 
slowly  sipped  each  morning  directly 
on  arising.  Intestinal  fermentation, 
the  bane  of  so  many  anemics,  is  best 
treated  dietetically  (eggs  are  noto- 
rious offenders ),  by  intestinal  irriga- 
tion, by  the  administration  of  cultures 
of  the  lactic  acid  bacillus,  and  by  the 
use  of  B-naphthol,  salol,  bismuth 
salicylate,  phenol,  and  similar  anti- 
fermentative  drugs.  In  patients  with 
troublesome  nervous  symptoms  stron- 
tium bromide  and  the  valerianates  of 
iron,  quinine,  and  zinc  are  helpful  ad- 
juncts to  the  therapeusis  suggested 
above. 

Alimentary  fermentation  being  in 
great  measure  responsible  for  the  blood 
deterioration  of  anemic  states,  lysol  is 
a  good  intestinal  antiseptic  to  correct 
this  condition.  Under  its  influence  the 
movements  from  the  bowels  become 
fewer,  formed,  less  foul,  and  free  from 
mucus;  the  appetite  becomes  increased, 
and  the  patients  rapidly  gain  strength. 
The  drug  is  given  in  capsules  containing 
each  lyi  minims;  one  capsule  every  two 
hours.  F.  Burges  (Miinch.  med.  Woch., 
Nu.  9,  S.  416,  1905). 

Case  of  probable  hemophilia  in  a  child 
of  2  years.  The  anemia  from  the  re- 
peated losses  of  blood  was  combated  by 
injection  of  from  10  to  18  c.c.  of  de- 
fibrinated  blood  from  healthy  adults. 
The  improvement  under  these  injections 
was  pronounced  and  striking,  and  the 
restoration  of  normal  conditions  in  the 
blood  was  accompanied  by  improvement 
in  the  general  health.  Five  of  these 
injections  were  made  in  the  course  of 
six  weeks.  It  is  useless  to  attempt  this 
transfusion  of  blood,  according  to  the 
writer,  when  the  blood-producing  ap- 
paratus is  irreparably  injured.  It  should 
not  be  done  as  a  last  resort,  but  should 
be  tried  as  early  as  possible  when  ane- 
mia in  children  is  assuming  a  grave 
form.  The  injections  were  made  under 
the  skin  of  the  thigh.  Some  substance 
in  the  serum  evidently  acts  as  a  stim- 
ulus   for    the   blood-producing   organs. 


ANEMIA,    SECONDARY    (DA  COSTA). 


663 


Schelblo  (Jahrh.  f.  Kindorhoilk.,  Oct., 
1908). 

Ill  aiKMiiiri  duo  to  autointo.xication 
from  the  gastrointestinal  tract,  as  often 
occurs  in  chlorosis :  1.  I'avor  gastric 
functions  by  proper  diet.  2.  Secure  reg- 
ular bowel  movements  by  laxatives.  3. 
Begin  the  use  of  iron,  giving  following 
pill:  Subcarbonate  of  iron,  0.10  gram 
(V/2  grains)  ;  powdered  aloes,  0.02  gram 
iVi  grain)  ;  extract  of  rhubarb,  0.05 
gram  (^  grain)  ;  two  pills  before 
meals.  Huchard  and  Fiessinger  (Revue 
•     de  therap.,  March  IS,  1910). 

The  gastric  and  hyper-  esthesia  in 
anemia  and  chlorosis  were  favorably 
inHuenced  in  several  instances  by  alu- 
minum silicate,  given  in  the  form  of 
neutralon,  in  doses  of  ^  to  1  dram  in 
3  ounces  of  water,  one-half  to  one  hour 
before  meals.  Rosenheim  and  Ehrmann 
(Deut.  med.  Woch.,  Jan.  20,  1910). 

In  the  management  of  acute  ane- 
mias of  grave  character  {i.e.,  post- 
hemorrhagic variety)  the  direct  trans- 
fusion of  an  homologous  blood,  by 
Crile's  or  by  Carrel's  method,  may 
prove  to  be  a  life-saving  expedient. 
The  technique  and  other  details  of  this 
operation  are  discussed  elsewhere  in 
this  work.     (See  Transfusion.) 

Seven  cases  of  severe  anemia  greatly 
benefited  by  transfusion  of  only  S  c.c. 
(75  minims)  of  human  blood.  No 
benefit  was  observed  in  cases  of  leu- 
kemia. Transfusion  of  this  amount  is 
generally  harmless,  though  the  blood 
from  certain  persons  showed  some 
toxicity.  Weber  (Deut.  Archiv  f.  klin. 
Med.,  Sept.  4,  1909). 

Four  cases  of  severe  anemia  greatly 
benefited  by  intramuscular  injections 
of  defibrinated  blood.  The  writer 
drew  off  venous  blood  from  a  healthy 
subject  into  a  small  flask,  stirred  for 
ten  or  fifteen  minutes,  filtered  through 
wool,  and  incubated  for  one-half  to  one 
hour.  He  then  injected  10  to  30  c.c.  in 
the  gluteal  muscles ;  the  procedure  is 
almost  painless.  Arsenic  in  increasing 
doses  should  be  given  at  the  same  time. 


liuber     (Deut.    med.    Woch.,    June    9, 
1910). 

Observations  on  twenty  dogs  killed 
by  chloroform  and  resuscitated  after 
periods  varying  from  three  to  fourteen 
minutes,  with  a  view  to  determining  the 
limits  of  recovery  after  a  total  anemia 
of  the  nervous  system.  In  human  resus- 
citation the  technique  i"  as  follows  :  The 
patient,  in  the  prone  posture,  is  sub- 
jected at  once  to  rapid  rhythmic  press- 
ure on  the  chest,  with  one  hand  on  each 
side  of  the  sternum.  This  pressure 
produces  artificial  respiration  and  a 
moderate  artificial  circulation.  A  can- 
nula is  inserted,  toward  the  heart,  into 
an  artery.  Normal  saline,  Ringer's,  or 
Locke's  solution,  or,  in  their  absence, 
sterile  water,  or,  in  extremity,  even  tap 
water  is  infused  by  means  of  a  funnel 
and  rubber  tubing.  But  as  soon  as  the 
flow  has  begun,  the  rubber  tubing  near 
the  cannula  is  pierced  with  the  needle 
of  a  hypodermic  syringe  loaded  with 
1 :  1000  adrenalin  chloride,  and  from  15 
to  30  minims  is  at  once  injected.  The 
injection  is  repeated  in  a  minute  if 
needed.  •  Synchronously  with  the  injec- 
tion of  the  adrenalin  the  rhythmic  press- 
ure on  the  thorax  is  brought  to  a 
maximum.  The  resulting  artificial  cir- 
culation distributes  the  adrenalin,  that 
spreads  its  stimulating  contact  with  the 
arteries,  bringing  a  wave  of  powerful 
contractions  and  producing  a  rising 
arterial,  hence  coronary,  pressure.  When 
the  coronary  pressure  rises  to,  say,  40 
mm.  or  more,  the  heart  is  likely  to 
spring  into  action.  Just  as  soon  as  the 
heart-beat  is  established  the  cannula 
should  be  withdrawn.  Bandaging  the 
extremities  and  abdomen  tightly  over 
the  masses  of  cotton  is  very  useful. 
From  a  personal  experience  in  attempts 
at  resuscitation  of  the  human  being  it 
became  apparent  that  the  human  heart 
seems  to  respond  even  more  readily  than 
the  heart  of  a  dog.  Crile  (Amer.  Jour. 
Med.  Sci.,  Apr.,  1909 ;  Jour.  Amer.  Med. 
Assoc,  May  1,  1909). 

Hydrotherapy  and  general  mas- 
sage must  be  regarded  as  most  useful 
aids  to  the  drug  treatment  of  anemia, 
and  such  measures,  when  sanely  car- 


664 


ANESTHESIN. 


ried  out,  will  do  much  to  promote 
adequate  excretion  and  secretion,  to 
maintain  a  healthy  balance  of  the 
blood  and  lymph  streams,  and  to 
stimulate  oxygen  and  carbon  dioxide 
interchange.  A  regime^  of  fresh 
air,  sunshine,  and  gentle  exercise 
is  of  great  value,  added  to  the  fore- 
going hygienic  measures,  and  in  this 
connection  it  is  interesting  to  recall 
Gardinhhi's  statement,  recently  voiced 
by  Pope  (N.  Y.  Med.  Jour.,  No- 
vember 2,  1907),  that  the  presence  of 
sunlight  promotes  the  absorption  of 
iron  from  the  liver,  where  this  metal, 
after  ingestion,  is  presumably  stored 
in  no  inconsiderable  quantity. 

J.  C.  Da  Costa,  Jr., 

Philadelphia. 

ANEMIA,  SPLENIC.     See 

Spleen,  Diseases  of, 

ANESIN.     See  Chloretone. 

ANESTHESIA.  See  Various 
Anesthetics:  .  Ether,    Chloroform, 

ETC. 

ANESTHESIN.  — Anesthesin  is, 
chemically,  ethyl  para-aminobenzoate  [Cq- 
H4.NH2.COOC2H5].  It  occurs  as  a  white, 
odorless,  and  tasteless  powder,  almost  in- 
soluble in  cold  water,  with  difficulty  solu- 
ble in  hot"*water,  sparingly  soluble  in  fatty 
oils  (2  to  3  per  cent.)  and  in  dilute  glyc- 
erin, easily  soluble  in  alcohol,  ether,  chlo- 
roform, benzene,  and  acetone.  It  melts 
at  90°  to  91°  C.  Though  decomposed  by 
prolonged  boiling,  it  can  be  rendered 
sterile  without  deterioration  when  dis- 
solved in  oils.  Alkalies  and  alkaline  car- 
bonates are  incompatible  with  it,  removing 
the  ethyl  group  to  form  alcohol  and  set- 
ting free  para-aminobenzoic  acid. 

PHYSIOLOGICAL  ACTION.  — The 
most  conspicuous  feature  of  anesthesin  is 
its  local  anesthetic  property.  The  drug 
differs  radically  from  cocaine  in  that  it  is 
but  very  feebly  toxic  and  is  insoluble  in 
water.     The  low  toxic  power  was   shown 


in  the  experiments  of  Binz,  who  adminis- 
tered 0.6  Gm.  (10  grains)  of  the  drug  in 
20  c.c.  of  oil  by  stomach  tube;  on  the  next 
day  the  animal  was  in  good  health,  with 
urine  normal.  The  dose  required  to  kill 
was  found  to  be  1.15  Gm.  (18  grains)  pei 
kilo  of  animal,  the  symptoms  produced 
being  paralysis,  gradual  loss  of  sensibility 
in  the  hind  limbs,  and  dyspnea  terminat- 
ing in  asphyxia.  The  drug  was  also  ad- 
ministered intravenously  in  dogs  and  in- 
traperitoneally  in  guinea-pigs,  with  simi- 
lar results  indicative  of  a  low  degree  of 
toxicity. 

The  intoxication  produced  by  anesthesin 
is  in  some  ways  comparable  to  that  of  acet- 
phenetidin ;  massive  doses  lead  to  the  forma- 
tion of  methenioglobin,  with  consequent 
methemoglobinuria. 

Anesthesin  placed  upon  the  tongue  pro- 
duces a  feeling  of  numbness  in  two  to 
three  minutes.  By  virtue  of  the  insolu- 
bility of  this  substance,  its  anesthetic 
action  is  more  strictly  localized  than  that 
of  cocaine.  It  is  also  feebler,  but  is  more 
enduring.  It  is  said  to  exert  no  action  on 
the  vessels  at  the  site  of  application,  caus- 
ing neither  vasoconstriction  nor  vasodila- 
tion. Over  orthoform  it  has  the  advan- 
tages of  being  more  stable  and  practically 
non-irritating. 

THERAPEUTIC  USES.  — Internally, 
anesthesin,  as  first  demonstrated  by  von 
Noorden,  is  useful  in  conditions  of  gastric 
hyperesthesia,  including  nervous  dyspepsia 
and  gastric  ulcer.  The  dose  is  0.2  to  0.5 
Gm.  (3  to  7y2  grains)  ten  to  fifteen  minutes 
after  the  ingestion  of  food.  In  laryngeal 
tuberculosis  an  insufflation  of  anesthesin 
has  been  found  by  Courtade  to  arrest  the 
severe  pain  and,  therefore,  the  dysphagia 
for  nearly  forty-eight  hours.  Earp  found 
it  very  useful  in  very  painful  bleeding  ex- 
ternal hemorrhoids.  The  bowels  were 
moved  freely  by  enemas,  hot  applications 
were  used  freely,  and  the  following  oint- 
ment was  applied  twice  daily: — 

B  Anesthesin 15  grs.   (1   Gm.). 

Ergotin    1    dr.    (4    Gm.). 

Ichthyol    30  mins.   (2  Gm.) . 

Lanolin    3  drs.  (12  Gin.). 

Petroleum  ..to  make     1  oz.  (31  Gm.). 

Earp  also  found  anesthesin  useful  in 
perineal  eczema  which  had  not  yielded  to 
other  measures.  S. 


ANEURISM    (BABCOCK). 


665 


ANEURISM.  —DEFINITION.— 

An  abnormal  circumscribed  blood- 
tumor  containing'  a  cavity  communi- 
cating with  an  artery.  An  aneurism 
consists  of  a  sac,  neck,  and  contents. 
The  contents  include  liquid  blood,  co- 
agula,  and  laminated  fibrin.  Aneu- 
risms vary  in  size  from  that  of  a  millet 
seed  to  that  of  a  child's  head.  In 
order  of  frequency  aneurisms  involve 
the  thoracic  aorta,  popliteal  artery,  fem- 
oral artery,  abdominal  aorta,  subclavian 
artery,  innominate  artery,  axillary 
artery,  iliac  artery,  and  the  cerebral 
and  pulmonary  arteries. 

VARIETIES.— Congenital.  —  Con- 
genital aneurisms  are  extremely  rare, 
but  they  have  been  reported  involving 
the  abdominal  aorta  and  ductus  Botalli. 
A  rare  congenital  deficiency  of  the 
elastic  elements  of  the  walls  of  the 
arteries  may  be  the  cause  of  multiple 
aneurisms,  especially  involving  the 
smaller  arteries  of  the  body. 

Idiopathic.  —  Idiopathic  aneurisms 
are  those  arising  without  obvious 
traumatic  injury  to  the  vessel  -vvall. 
They  are  usually  dependent  upon  dis- 
ease of  the  arter}^,  and  constitute 
most  of  the  aneurisms  involving  the 
great  vessels  of  the  trunk,  and  the 
smaller  aneurisms  of  the  brain  and 
other  viscera. 

Traumatic. — Traumatic  aneurisms 
are  those  resulting  from  mechanical  in- 
juries sustained  by  the  arterial  wall, 
either  in  the  form  of  a  contusion,  in- 
cision, or  laceration. 

Hernial. — Hernial  aneurisms  are 
usually  small  traumatic  aneurisms  pro- 
duced by  the  bulging  of  the  inner  tunic 
through  the  divided  outer  layers  of  the 
arterial  wall. 

True. — True  aneurisms  are  those 
having  walls  formed  by  the  normal 
coats  of  an  artery.    It  is  rare,  however. 


to  find  an  aneurismal  sac  in  which  in- 
tima,  media,  and  adventitia  can  all  be 
demonstrated. 

False. — False  aneurisms  are  those 
in  which  the  sac  is  formed  b}^  tissues 
other  than  those  derived  from  the 
wall  of  the  artery.  They  follow  arte- 
rial incisions  or  ruptures,  but  even 
W'ith  these  false  sacs  the  endothelium 
proliferates  from  the  intima  of  the 
artery  into  the  sac  and  finally  tends 
to  line  it. 

Diffuse. — Diffuse  aneurisms  are 
false  aneurisms  resulting  from  an  ex- 
tensive extravasation  of  blood  from 
an  open  artery.  As  a  rule,  they  are 
due  to  traumatism,  but  the}"  also  re- 
sult from  the  spontaneous  rupture  of 
a  diseased  artery. 

Dissecting.  —  Dissecting  aneurisms 
are  those  in  which  the  aneurismal  sac 
lies  betw-'een  the  coats  of  the  artery. 
As  a  rule,  they  have  two  mouths,  the 
blood  entering  through  one  opening, 
separating  the  layers  of  the  arterial 
walls,  and  then,  at  some  distance,  re- 
communicating  by  a  second  opening 
with  the  arterial  stream.  These  oc- 
cur most  frequently  in  the  abdominal 
aorta  and  may  produce  a  very  exten- 
sive separation  of  the  arterial  coats. 

Embolic. — Embolic  aneurisms  are 
those  resulting  from  the  lodgment  of 
emboli.  By  some  they  are  attributed  to 
the  laceration  of  the  walls  of  the  small 
vessels  by  calcareous  embolic  particles. 
It  is  evident  that  they  may  also  result 
from  degenerative  or  inflammlatory 
changes  of  the  arterial  wall,  secondary 
to  the  lodgment  of  the  embolus. 

Embolomycotic  aneurisms  develop 
during  the  course  of  endocarditis  and 
occasionalljr  during  some  of  the  acute 
infectious  diseases,  which  form  a  dis- 
tinct group  by  themselves,  differing  in 
pathogenesis,  clinical  course,  and  prog- 
nosis from  those  developing  secondary 


666 


ANEURISM    (BABCOCK). 


to  chronic  arterial  changes.  Thej^  have 
been  recognized  since  1851.  They  may 
develop  in  one  of  three  ways.  Most 
commonly  they  follow  an  endarteritis 
associated  with  lodgment  of  infected 
emboli  at  the  bifurcation  of  arteries. 
A  few  cases  have  been  reported  which 
developed  during  the  course  of  infec- 
tious diseases  unaccompanied  by  endo- 
cardial changes.  The  possibility  of 
traumatic  origin  is  also  supported  by 
the  observation  of  Ponfick  and  Thoma 
of  calcified  emboli  in  the  arterial  wall 
and  projecting  into  the  aneurism. 
Clinically,  embolomycotic  aneurisms  dif- 
fer from  those  following  chronic  arte- 
rial changes:  (1)  in  developing  at  an 
earlier  age ;  (2)  in  frequently  being 
multiple,  acute  and  chronic  forms  often 
occurring  in  the  same  individual ;  (3) 
in  the  frequent  involvement  of  visceral 
arteries,  and  (4)  in  the  tendency  to 
remain  small.  A  number  of  cases  have 
been  reported  in  which  no  satisfactory 
explanation  is  given  of  the  cause. 
About  one-fourth  of  the  cases  observed 
developed  during  the  third  decade  of 
life,  and  about  one-fourth  during  the 
second. 

They  are  much  more  frequent  in 
males,  although  the  authors  have  been 
unable  to  demonstrate  the  reasons  for 
this  satisfactorily.  They  have  collected, 
including  their  own  cases,  96  aneurisms 
of  this  class  occurring  in  65  patients, 
they  frequently  being  multiple,  and  re- 
port 3  cases  observed  by  themselves. 
The  largest  proportion  of  these  aneu- 
risms occurred  in  the  superior  mesen- 
teric and  cerebral  arteries,  and  in  the 
aorta,  which  is  in  marked  contrast  to 
the  distribution  of  the  ordinary  type 
of  chronic  aneurisms,  which  rarely 
occur  in  the  superior  mesenteric  or 
cerebral  arteries.  There  is  nothing 
characteristic  in  the  symptoms,  and  they 
are  not  often  suspected  until  fatal  ab- 
dominal or  cerebral  hemorrhage  occurs. 
Bacteria  have  been  found  within  the 
wall  of  the  aneurism,  showing  the 
bacteriological  relationship  between  the 
vegetations  on  the  heart  valves  and  the 
clot  in  the  aneurism.  The  forms  are 
usually  the  streptococcus  and  staphy- 
lococcus, though  other  species  have  been 


reported.  In  2  of  the  author's  cases, 
examinations  revealed  the  pneumococ- 
cus.  This  infection  of  the  aneurisms 
complicates  any  operation,  the  patients 
being  usually  in  a  critical  condition  and 
not  enduring  surgery  well.  Dean  Lewis 
and  V.  L.  Schrager  (Jour.  Amer.  Med. 
Assoc,  Nov.  27,  1909). 

Miliary.  —  Miliary  aneurisms  are 
very  minute  aneurisms  most  fre- 
quently observed  in  the  brain  or 
lungs.  They  involve  small-  or  me- 
dium- sized  arteries  and  often  occur 
in  great  numbers. 

Fusiform  or  Ectatic.  —  In  these 
forms  the  weakened  arterial  walls 
yield  in  every  direction,  forming  a 
fusiform,  or,  rarely,  a  somewhat  cylin- 
drical, enlargement.  The  three  coats 
of  the  artery  may  be  demonstrated  in 
the  sac ;  usually  there  is  little  clot 
present,  and  there  may  be  few  symp- 
toms, unless  through  weakness  of  a 
part  of  the  wall  a  sacculated  aneurism 
follows.  The  walls  of  the  fusiform 
aneurism  may  be  thicker  than  that  of 
the  adjacent  artery. 

Sacculated. — Sacculated  aneurisms 
are  due  to  the  bulging  of  one  side  of  an 
artery.  The  elastic  and  muscular  layers 
of  the  artery  are  not  found  in  the  walls 
of  the  sac, 

ETIOLOGY.  —  Aneurisms  result 
from  conditions  weakening  the  ar- 
terial wall  and  increasing  the  blood- 
pressure. 

Race.  —  The  Anglo-Saxon  race  is 
most  frequently  affected;  the  English 
more  than  the  American,  a  condition 
attributed  to  the  greater  consumption 
of  alcohol  in  England.  Aneurism  is 
rare  in  the  Asiatic  races  and  in  Italy. 
It  is  three  times  as  prevalent  in  the 
American  negro  as  in  the  white  race. 

Age. — Aneurism  is  most  frequent  be- 
tween the  ages  of  30  and  50,  a  period 
when  degenerative  changes  in  the  ar- 


ANEURISM    (BABCOCK). 


667 


teries    are    especially    found    in    those 
engaged  in  laborious  physical  work-. 

Sex. — Men  are  affected  ten  times  as 
frequently  as  women,  excepting  the 
carotid  and  dissecting  forms  of  aneu- 
rism, w^hich  occur  more  frequently  in 
women.  The  more  laborious  occupa- 
tions of  men  and  their  greater  tendency 
to  dissipation  and  excess  explain  the  in- 
fluence of  sex. 

Soldiers,  sailors,  athletes,  cab  driv- 
ers, furnace  men,  and  others  engaged 
in  violent,  but  intermittent  exercise  are 
especially  predisposed  to  aneurism.  It 
is  eleven  times  more  frequent  in  the 
English  army  than  in  the  civilian,  and 
is  much  more  frequent  in  soldiers  than 
in  sailors,  a  condition  attributed  to  the 
pressure  and  strain  from  poorly  fitting 
clothing  and  heavy  accoutrements.  Cab 
drivers,  apparently  from  the  pull  upon 
the  arms,  are  especially  susceptible  to 
thoracic  aneurism. 

Vessels  at  the  point  of  flexion  and 
extension,  such  as  the  popliteal  and 
iliacs,  or  under  greater  strain,  such  as 
those  of  the  right  arm  rather  than  the 
left,  are  more  frequently  involved.  Oc- 
casionally symmetrical  aneurisms,  as 
double  popliteal  aneurisms,  occur. 

Those  conditions  that  produce  a 
weakening  of  the  arterial  wall,  espe- 
cially all  the  causes  of  arteriosclerosis 
and  atheroma,  are  important  predis- 
posing causes  to  aneurism.  These  in- 
clude syphilis,  alcoholism,  rheumatism, 
gout,  and  the  action  of  mineral  poisons 
like  lead. 

Arterial  disease  appears  to  be  rare, 
almost  unknown,  in  animals.  Syphilis, 
being  probably  peculiar  to  man,  is  by 
this  observation  placed  more  firmly  in 
the  list  of  etiological  factors.  Arterial 
disease  in  children  under  6  years,  even 
in  those  who  are  victims  of  congenital 
syphilis,  is  practically  unknown.  In 
those  from  6  to  15  years  it  is  rare.  It 
is  found  in  the  initial  stage  most  com- 


monly between  the  ages  of  30  and  40 
years.  The  teratological  factor,  though 
an  undeterminable  one,  is  of  great  im- 
portance. Arterial  disease  seems  to  be 
attributable  to  syphilis  in  about  32  per 
cent. ,  to  tuberculosis  in  about  16  per 
cent.  The  facts  presented  go  to  show 
that  the  colored  race  is  affected  about 
four  times  more  frequently  than  the 
white. 

General  arteriosclerosis  seems  to  be 
not  commonly  found  with  aneurism,  and 
its  presence  may  be  considered  as  evi- 
dence against  the  probable  development 
of  aneurism. 

Staining  with  selective  stains  and 
treating  with  a  chemical  which  digests 
tissue  show  the  elastic  tissue  to  be 
free  of  histological  alterations,  sug- 
gesting that  this  tissue  undergoes  physi- 
cal or  molecular  rather  than  hi'^tological 
change.  C.  N.  B.  Camac  (Amer.  Jour. 
Med.  Sci.,  May,  1905). 

The  influence  of  rheumatism  is  one 
of  great  importance,  especially  in  young 
patients.  The  writer,  working  with 
Renon,  has  recently  published  some  im- 
portant '  observations  relative  to  this 
subject.  According  to  the  cases  col- 
lected by  this  author,  the  average  age 
is  from  10  to  16  when  the  patients  have 
usually  had  several  attacks  of '  acute 
rheumatism.  Repetition  of  the  disease 
is  regarded  as  an  essential  factor.  The 
appearance  of  aneurism  is  preceded  for 
some  time  by  the  signs  of  aortic  in- 
competence and  hypertrophy  of  the 
heart.  After  a  period  of  considerable 
latency,  the  symptoms  and  signs  of 
aneurism  appear  rapidly.  They  are 
dyspnea,  especially  marked  after  effort, , 
and  characterized  by  forced  inspiration 
without  actual  oppression.  After  a 
short  time  this  dyspnea  becomes  per- 
manent, though  occasionally  varied  by 
pseudoasthmatic  crises,  sometimes  at- 
tacks of  pain  resembling  angina  pec- 
toris. The  attacks  usually  appear  dur- 
ing the  first  sleep.  The  patient  retires 
to  rest  in  his  ordinary  condition,  but 
suddenly  awakes  in  great  agony,  com- 
plaining of  a  feeling  of  constriction  in 
front  of  the  chest,  air  hunger,  desire 
to  cry  out,  and  violent  inspiratory 
efforts  are  made.     The  crisis  may  last 


668 


ANEURISM    (BABCOCK). 


from  a  quarter  to  one  hour,  and  then 
gradually  disappear.  Occasionally  the 
crises  are  entirely  painful  without  res- 
piratory trouble.  They  may,  therefore, 
be  pseudoasthmatic  or  pseudoanginal. 
Considerable  intervals  may  elapse  be- 
tween them,  for  in  one  case  quoted  by 
the  author  they  numbered  2  or  3  dur- 
ing the  year ;  in  others  they  are  more 
frequent,_  occurring  once  a  month,  or 
even  daily.  The  diagnosis  is  confirmed 
by  the  rapid  appearance  of  physical 
signs.  These  aneurisms,  as  a  rule, 
affect  the  upper  right  costal  area,  and 
do  not  differ  from  those  usually  ob- 
served in  other  cases.  Aortic  aneurism 
in  young  rheumatic  subjects  may  de- 
velop fully  in  the  course  of  a  few 
weeks,  sometimes  in  succeeding  stages 
corresponding  to  the  rheumatic  crisis. 
After  each  crisis  there  may  be  tem- 
porary improvement,  due  to  retrocession 
of  the  tumor.  This  improvement  is  re- 
versed by  a  fresh  crisis  of  articular 
inflammation.  The  condition  is,  there- 
fore, progressive,  and  there  is  little  hope 
of  obliteration  taking  place  in  the  sac. 
Prognosis  is  usually  fatal,  death  often 
occurring  suddenly  either  from  hemor- 
rhage or  as  the  result  of  an  anginal 
seizure. 

■  Treatment  can  only  be  directed 
toward  symptoms,  nitrites  being  given 
for  dyspnea  and  pain,  and  salicylates 
should  not  be  omitted  in  view  of  the 
rheumatic  nature  of  the  disease.  Fey- 
taud  (These  de  Paris,  1906;  Brit.  Med. 
Jour.,  Jan.  12,  1907). 

Generalized  arteriosclerosis  or  endar- 
teritis is  seldom  followed  by  aneurism 
of  any  of  the  large  blood-vessels, 
the  pathogenic  conditions  of  which 
are  forms  of  progressive  periarteritis, 
finally  causing  perforation  of  the  elas- 
tic membrane  of  the  affected  vessel. 
Aneurisms  of  this  kind — those  due  to 
traumatism  being  excluded — have  an 
infective  origin,  and  are  the  result  of 
tuberculosis,  syphilis,  or  malaria.  Lan- 
cereaux   (Rev.  de  chir.,  No.  8,  1906). 

Aneurism  of  the  thoracic  aorta  is 
undoubtedly  a  syphilitic  disease,  though 
aortic  strain  from  hard  work  where 
the  tissues  are  already  degenerated  by 
alcoholic    excesses    must   certainly   pre- 


dispose. A  strong  alcoholic  history  was 
obtained  in  more  than  40  per  cent,  of 
the  writer's  cases.  Of  225  cases  of 
aneurism,  179  were  sacculated,  39  fusi- 
form, and  7  dissecting.  In  much  the 
larger  proportion  of  cases  the  aneurism 
occurs  in  the  transverse  portion  of  the 
arch  of  the  aorta.  Drummond  (Brit. 
Med.  Jour.,  June  13,  1908). 

Cardiac  hypertrophy,  plethora,  and 
renal  disease  are  also  factors.  Experi- 
mentally, aneurism  may  be  produced 
by  the  repeated  introduction  of  adren- 
alin into  the  circulating  stream. 

PATHOLOGY.— Idiopathic  aneu- 
risms develop  in  an  area  of  atheroma, 
in  the  situation  of  an  old  scar,  the  point 
of  lodgment  of  an  embolus,  or  other 
weak  area  in  the  arterial  wall.  All 
forms  of  aneurism  are  lined  by  endo- 
thelium, excepting  the  fusiform  aneu- 
risms ;  the  media  of  the  artery  does  not 
constitute  a  layer  of  the  abnormal  sac. 
This  is  important,  and  it  means  not  only 
that  the  normal  muscular  and  elastic 
coats  are  absent,  but  that  the  vasa  va- 
sorum  upon  which  the  arterial  wall 
depends  for  its  nourishment  is  lacking. 
The  sacs  of  all  saccular  aneurisms  tend, 
therefore,  to  be  weak  and  from  the 
blood-pressure  to  become  progressively 
distended. 

In  the  fusiform  aneurism  all  the 
layers  of  the  arterial  walls  may  remain 
and  the  wall  of  the  sac  may  be  thicker 
than  that  of  the  normal  artery,  the  in- 
tima  being  thickened  by  atheroma,  the 
adventitia  by  the  deposit  of  fibrous  tis- 
sue, while  the  middle  coat  is  thinned. 
As  the  inner  coats  of  an  artery  consti- 
tute' not  less  than  three-fourths  of  the 
thickness  of  its  wall,  containing  the 
elastic  and  muscular  layers,  and  also 
the  vasorum  supplying  the  walls  with 
nourishment,  the  thinning,  absence,  or 
damage  to  these  structures  means  a 
weak  and  poorly  resilient  wall  for  the 
aneurismal  sac. 


ANEURISM    (BABCOCK). 


669 


In  sacculated  aneurisms  there  is 
usually  a  progressive  deposit  of  layers 
of  fibrin  against  the  wall  of  the  sac, 
tending  to  strengthen  the  walls  and  to 
lessen  the  fluid  contents.  The  lessen- 
ing of  the  fluid  contents  is  important, 
as  the  pressure  on  the  sac  wall  varies 
as  the  square  of  the  diameter  of  the 
cavity  which  contains  the  fluid. 

At  times  the  blood-clot  is  deposited 
in  progressive  layers  until  the  entire 
sac  is  filled,  resulting  in  a  spontaneous 
cure.  The  blood-clot  at  the  periphery 
is  white,  laminated,  and  fibrous,  al- 
though rarely  organized  into  the  true 
fibrous  tissue,  the  lack  of  vasorum  pre- 
venting vascularization.  The  aneurism, 
therefore,  may  consist  of  a  sac  or  body, 
which  in  the  sacculated  form  may  com- 
municate by  neck  and  opening  with  the 
artery.  The  sac  is  strengthened  on  the 
outer  side  by  the  deposit  of  fibrous  tis- 
sue, an  evidence  of  the  reaction  and 
irritation  of  the  tissues  against  which 
the  aneurism  presses. 

The  sac  may  contain  peripherally 
white,  laminated  clot;  then  a  layer  of 
softer,  red  blood-clot,  and  finally  fluid 
blood  communicating  with  the  blood- 
stream. In  the  cylindrical  and  fusi- 
form aneurisms  little  or  no  lining  clot 
may  be  present. 

The  size  and  shape  of  the  sac  are 
modified  by  adjacent  pressure.  Rota- 
tion of  the  sac  may  occur  so  that  in  a 
fusiform  aneurismal  sac  the  orifices  of 
the  efirerent  and  afferent  trunks  may  lie 
at  the  sides  or  at  the  equator  of  the  sac, 
rather  than  at  the  poles. 

Matas  classifies  aneurisms  by  the 
number  of  orifices  which  connect  them 
with  the  parent  artery.  These  orifices 
may  only  be  accurately  determined  af- 
ter the  opening  of  the  sac.  Fusiform 
aneurisms  have  two  distinct  orifices ; 
saccular    or    sacciform    aneurisms    are 


those  which  are  connected  with  the 
lumen  of  the  parent  vessel  by  a  single 
circular,  ovoid,  or  elongated  opening 
through  which  the  blood  flows  in  and 
out  the  sac. 

The  sac  of  the  aneurism  may  have 
many  collateral  branches  corresponding 
somewhat  with  the  branches  normally 
given  ofi:  by  the  segment  of  the  arterial 
wall  forming  the  aneurism.  These  collat- 
erals may  be  functional  or  impervious 
and  containing  thrombi.  The  perianeu- 
rismal  circulation  may  be  very  impor- 
tant in  maintaining  the  collateral  circu- 
lation after  operation  .upon  the  sac.  An 
aneurism  influences  the  blood-stream, 
absorbing  the  cardiac  wave,  so  that  the 
pulse  distal  to  the  sac  is  delayed  and 
weakened.  To  compensate  for  this  the 
heart  may  hypertrophy  and  anastomotic 
channels  form. 

The  aneurism  may  so  press  upon  the 
main  vessels  as  to  completely  inter- 
rupt the  circulation  beyond  the  sac. 
The  adjacent  tissues  are  variously 
afifected.  Bone  is  eroded  and  pro- 
gressively destroyed  by  the  continuous 
pressure,  cartilage  being  much  more 
resistant  than  bone. 

Nerves  are  stretched,  compressed, 
and  flattened,  at  times  destroyed,  giving 
rise  to  paresthesia  and  more  rarely 
paralysis.  Adjacent  veins  may  be  com- 
pressed with  the  production  of  cyano- 
sis and  edema,  and  rarely  erosion  and 
perforation  in  the  venous  channel 
occur.  Mucous  canals  are  compressed 
and  displaced,  while  .fibrous  tissue,  ten- 
dons, and  fascia  are  flattened,  stretched, 
and  often  incorporated  into  the  sac. 

Thrombi  may  form. in  tributary  ves- 
sels, and  emboli  may  result  from  the 
dislodgment  of  clot  or  fibrin.  Cerebral 
complications,  such  as  hemiplegia,  in- 
farcts in  the  internal  organs,  and  gan- 
grene of  the  extremities,  also  occur. 


670 


ANEURISM    (BABCOCK). 


SYMPTOMS.— Aneurismal  dilata- 
tion may  occur  suddenly  from  trauma- 
tism or  a  great  increase  of  intravascu- 
lar pressure  and  may  be  characterized 
by  sharp  pain  and  rapid  enlargement 
along  the  course  of  an  artery.  The 
sac,  however,  usually  forms  slowly  and 
at  first  without  pain  or  any  other 
symptom. 

Case  of  a  woman  aged  42  years, 
attended  by  remarkable  features.  The 
aneurism  was  eroded  and  perforated 
the  sternum  in  two  places  without  ever 
causing  pain  or  any  other  pressure 
symptoms;  it  presented  externally  as  a 
tumor,  and  then  disappeared  under 
treatment  by  iodide  of  potassium,  the 
skin  rupturing  without  letting  out  any 
blyod.  This  series  of  events  was  re- 
peated several  times  in  the  course  of 
seven  years.  Death  occurred  from  the 
sudden  bursting  of  the  aneurism  as  the 
patient  lifted  a  pitcher  of  water.  R.  C. 
Cabot  (Amer.  Jour.  Med.  Sci.,  April, 
1900). 

The  diagnosis  of  aortic  aneurism  still 
remains  in  obscure  cases  a  difficult  one, 
and  even  the  X-ray  examination  maybe 
misleading.  Attention  called  to  the 
frequency  with  which,  in  aneurism  of 
the  arch,  the  left  supraclavicular  groove 
is  obliterated  or  even  bulges,  and  the 
left  external  jugular  is  obviously  fuller 
than  the  right.  The  anatomical  reason 
lies  simply  in  the  compression  of  the 
left  innominate  vein  as  a  result  of  the 
dilated  arch.  A  mediastinal  tumor  may 
have  the  same  effect,  but  dilatation  in 
cases  of  aortic  insufficiency  is  apparently 
seldom  sufficient  to  effect  compression. 
Dorendorff  (Deut.  med.  Woch.,  Nov. 
31,   1902). 

Pain  is  one  of  the  earliest  and  most 
constant  symptoms  of  aortic  aneurism. 
It  was  the  first  and  most  severe  symp- 
toms in  about  half  of  the  author's 
cases.  It  is  possible  that  it  should  be 
absent,  though  there  may  be  dyspnea, 
cough,  and  cyanosis,  and  though  the 
sac  may  perforate  the  chest  wall  or 
erode  the  spine.  The  most  common 
situation  for  the  pain  is  in  the  region 
of    the    heart    itself,    radiating    to   the 


neck,  the  shoulder,  and  back,  and  down 
the  left  arm  or  both  arms.  In  some 
cases  the  abdominal  pain  is  severe. 
Several  distinct  varieties  of  pain  may 
be  recognized  in  this  disease :  1.  At- 
tacks of  true  angina,  having  paroxysms 
of  pain  of  maximum  intensity,  with 
radiation  to  the  arm.  2.  Sharp  neu- 
ralgic pain  due  to  pressure  on  the 
nerves,  perhaps  extending  along  the 
course  of  the  nerves,  and  associated 
with  herpes  when  the  descending  tho- 
racic aorta  is  implicated.  It  is  similar 
in  character  to  that  which  is  caused  by 
the  pressure  of  pelvic  tumors,  and  by 
disease  of  the  vertebrse,  and  it  may  be 
paroxysmal  in  character.  3.  Pain  of  a 
dull,  boring  character  which  is  present 
when  the  chest  wall  or  the  spine  is 
eroded  by  the  aneurismal  sac.  This  is 
the  form  of  aneurismal  pain  which  is 
most  enduring  and  most  severe.  It  is 
due  to  tension  and  stretching  of  fibrous 
and  bony  structures  rather  than  to 
pressure  upon  nerve  cords.  4.  Pain  re- 
ferred to  the  nerves  of  the  arms  or  the 
skin  in  the  precordial  region  or  to  the 
pectoral  or  sternomastoid  muscles. 

One  object  of  the  writer's  paper  was 
to  narrate  types  of  cases  in  which  at- 
tacks of  angina  pectoris  customarily 
precede  the  appearance  of  the  aneurism 
for  months  or  years.  The  paroxysms 
may  not  be  in  the  least  suggestive  of 
aneurism,  but  they  are  associated  with 
early  structural  changes  in  the  wall  of 
the  aorta.  In  sclerosis  of  the  aorta 
pain  is  not  necessarily  a  symptom,  the 
author  having  observed  this  fact  in 
syphilitic  patients.  With  lesions  of 
arteries  the  pain  may  be  the  most  in- 
tense, this  being  frequently  observed  in 
embolism,  thrombosis,  and  the  ligation 
of  vessels.  W.  Osier  (Med.  Chronicle, 
May,  1906). 

With  the  exception  of  the  rare  cases 
in  which  there  is  trouble  with  swallow- 
ing, the  early  symptoms  of  aneurism, 
manifested  by  pressure,  are  usually 
either  pain  or  disturbance  with  the  re- 
spiratory apparatus.  The  latter  may 
come  either  from  pressure  on  the  air 
passages  or  from  pressure  on  the  re- 
current laryngeal  nerve.  The  symp- 
toms frequently  simulate  those  of  heart 


ANEURISM    (BABCOCK). 


671 


disease,  and  their  true  meaning  is 
learned  partly  by  not  finding  a  cardiac 
condition  that  will  explain  the  symp- 
toms, and  partly  by  looking  for  and 
finding  evidence  of  an  aneurism. 

The  picture  of  aortic  aneurism  in  its 
earlier  stages  is  not  uniform,  but  varies 
widely  with  the  position  and  size  of  the 
aneurism.  There  are  no  pathognomonic 
signs.  The  most  characteristic  feature 
of  one  case  may  be  entirely  lacking  in 
the  next  one.  And  yet  a  careful  physi- 
cal examination  and  a  careful  consider- 
.  ation  of  the  physical  signs  and  symp- 
toms should  enable  the  detection  of  the 
existence  of  an  aneurism  of  the  ascend- 
ing or  transverse  arch  at  a  very  early 
stage.  The  X-ray  examination  is  of  use 
in  the  case  of  aneurisms  in  these  two 
parts  of  the  aorta  as  confirmatory  evi- 
dence, as  giving  more  definite  informa- 
tion in  some  respects,  and  sometimes 
(when  pulsation  is  seen)  in  deciding 
between  an  aneurism  and  a  solid  tumor. 
The  X-rays  may  detect  aneurisms  of  the 
descending  arch  and  the  descending 
thoracic  aorta  which  cannot  be  detected 
by  the  ordinary  methods  of  physical 
examination.  On  the  other  hand,  a 
negative  report  of  an  X-ray  examina- 
tion is  not  absolutely  conclusive  proof 
against  the  existence  of  an  aneurism. 

The  detection  of  an  aneurism  of  the 
arch  of  the  aorta  requires  no  greater 
skill  than  does  the  recognition  of  in- 
cipient tuberculosis.  It  is,  therefore, 
within  reach  of  the  general  practitioner, 
if  he  will  give  this  disease  equal  con- 
sideration with  tuberculosis.  When 
discovered  early,  the  treatment  is  not 
the  same  as  in  the  advanced  stages. 
Moderate  limitation  of  exertion  and 
mental  quietude  are  essential,  but  abso- 
lute rest  in  bed  is  not  necessary.  While 
the  disease  cannot  usually  be  cured,  life 
can  be  prolonged  in  comfort.  The 
vasodilators  are  the  most  useful  drugs 
so  far  as  medication  is  demanded.  H. 
D.  Arnold  (Amer.  Jour.  Med.  Sci., 
April,    1908). 

An  early  postive  diagnosis  of  aortic 
aneurism  is  obtainable  only  by  the 
X-ray.  Expansile  pulsation  is  not  con- 
stant. Abnormal  dullness  is  a  valuable 
sign  when  present.     The  most  constant 


sign  is  systolic  bruit,  which  was  present 
in  11  of  19  cases.  Tracheal  tugging 
occurred  in  but  2  cases.  The  earliest 
and  most  constant  symptoms  were 
dyspnea  and  cough.  Interference  with 
passage  of  bismuth  capsule  the  size 
of  a  quarter  through  esophagus  was 
found  present  in  every  case  tested 
(by  X-rays).  This  is  especially  valu- 
able in  small  aneurisms  growing  back 
from  the  transverse  part  of  the  arch, 
as  it  shews  the  esophageal  obstruction 
before  dysphagia  appears.  Lange  (Lan- 
cet-Clinic, Feb.  19,  1910). 

The  aneurism  forms  a  smooth  round 
or  oval  enlargement  in  the  course  of  an 
artery.  It  is  not  sensitive,  unless  in- 
flamed, is  not  adherent  to  the  overlying 
skin,  but  may  be  associated  with  edema 
and  venous  congestion  of  the  parts  dis- 
tal to  the  tumor.  The  sw^elling  has  an 
expansive  pulsation  up  to  the  time  that 
a  sufficiently  thick  layer  of  clot  forms 
within  the  sac  to  abolish  this  sign,  so 
that  the  symptoms  are  at  times  divided 
into  those  of  the  expansile  and  those  of 
the  non-expansile  stage.  The  artery 
distal  to  the  aneurism  gives  a  retarded 
and  feeble  pulse.  The  expansile  pul- 
sation may  be  less  marked  and  the 
tumor  softer  when  the  parts  are  ele- 
vated. The  pulsation  is  diminished  by 
pressure  upon  the  main  artery  prox- 
imal to  the  aneurism,  and  in  some  cases 
the  sac  may  then  become  softer  and 
collapse.  On  auscultation  a  systolic  or 
sometimes  a  double  rough  murmur  or 
bruit  is  heard,  loudest  at  the  proximal 
pole.  A  shadow,  emphasized  if  cal- 
careous deposits  are  present,  may  be 
shown  by  the  fluoroscope  or  skiagraph. 

Subjective  symptoms  include  pain 
from  the  stretching  and  compression  of 
nerves  and  the  arrest  of  the  venous  or 
lymphatic  circulation.  The  pressure 
and  erosion  of  bone,  especially  noticed 
in  aneurisms  of  the  aorta,  cause  the 
characteristic   boring,    so-called   osteo- 


672 


ANEURISM    (BABCOCK). 


pathic   pains    which   are   usually  more 
severe  at  night. 

In  the  skull  the  rushing  sound  and 
bruit,  headache,  and  the  evidences  of 
cerebral  pressure  or  irritation,  such  as 
choked  disk,  vomiting,  dilated  pupil, 
motor  and  sensory  disturbances,  and 
localizing  nerve  palsies,  may  be  present. 

When  an  aneurism  causes  paralysis 
of  the  third  nerve  alone,  it  is  uniformly 
seated  upon  the  trunk  of  the  internal 
carotid,  between  the  origins  of  the 
anterior  and  posterior  communicating 
arteries.  When  the  aneurism  involves 
the  origin  of  the  posterior  cerebral 
artery,  the  paralysis  of  the  third  nerve 
is  accompanied  by  paralysis  of  the 
corresponding  facial.  The  only  sub- 
jective symptoms  (besides  the  diplopia) 
are  pains  in  the  head  and  constant 
noises  upon  the  same  side  as  the  aneu- 
rism. These  cases  always  end  fatally. 
Pascheff   (Archiv  d'ophtal.,  Oct.,  1910). 

In  the  neck  the  situation  of  the 
tumor,  expansile  pulsation,  and  the  ef- 
fect upon  the  distal  vessels  are  charac- 
teristic symptoms. 

In  the  chest  the  recurrent  laryngeal 
nerve  frequently  is  involved  with  the 
production  of  rasping  voice,  spasm  or 
paralysis  of  the  vocal  cord,  and  brassy 
cough.  Pressure  upon  the  sympathetic 
may  produce  unilateral  sweating  and 
unilateral  contraction  or  dilatation  of 
the  pupil  as  well  as  tachycardia.  Pe- 
ripheral neuralgia  may  result  from 
compression  of  the  intercostals.  Com- 
pression of  the  phrenic  may  cause 
dyspnea  and  hiccough,  w^hile  pressure 
upon  the  esophagus  may  result  in 
dysphagia. 

Although  there  is  no  one  pathog- 
nomonic sign  of  thoracic  aneurism, 
there  are  certain  symptoms  and  signs 
taken  together  which  make  its  existence 
practically  certain.  The  pain,  often 
slight  and  not  complained  of  except 
after  particular  inquiry,  is  continuous, 
is  situated  near  and  to  the  left  of  the 


vertebral  column,  and  tends  to  radiate 
to  the  shoulder,  the  left  arm,  and  the 
neck.  Examination  of  the  chest  shows 
no  loss  of  resonance  on  the  left  side, 
but  the  resonance  is  not  increased  as  in 
pneumothorax.  At  the  same  time  the 
breath  sounds  are  dimini-hed  over  the 
left  lung — this  being  due  to  partial 
compression  of  the  left  bronchus.  The 
inspiratory  sound  is  shorter  over  the 
left  side,  the  first  period  of  inspiration 
being  inaudible  and  the  air  then  enter- 
ing with  a  rush,  as  though  a  valve  had 
been  opened.  On  inspection,  there  is 
relative  immobility  of  the  left  side  of 
the  chest,  or  in  some  cases  there  may 
even  be  definite  retraction.  If  the 
above  signs  be  present,  together  with 
dyspnea  on  effort,  in  a  patient  whose 
general  health  is  fairly  good  and  who 
has  no  sign  of  malignant  disease,  the 
presumption  of  the  existence  of  aneu- 
rism is  strong.  Inequality  of  the  pupils 
is  often  an  early  symptom.  Clement 
(Lyon  med.,  March  31,  1907). 

Tracheal  tugging  is  often  found  in 
aneurism  of  the  arch  of  the  aorta,  and 
is  due  to  the  transmission  of  the  aneu- 
rismal  pulsations  to  the  left  bronchus, 
and  is  detected  by  inclining  the  head 
and  lifting  the  larynx  and  trachea  by 
the  finger  and  thumb  caught  under  the 
hyoid  bone. 

Six  cases  illustrating  the  way  in 
which  an  aneurism  of  the  aorta  is  liable 
to  push  the  trache :  backward,  down- 
ward, and  toward  the  left,  and  thus 
pull  the  larynx  out  of  place.  This 
dragging  down  of  the  larynx  and  its 
deviation  to  the  left  and  back  may,  the 
writer  asserts,  be  regarded  as  a  reliable 
sign  of  aneurism  of  the  aorta.  Boinet 
(Bull,  de  I'Acad.  de  Med.,  Dec.  21, 
1909). 

Inanition  may  follow  in  the  rare  in- 
stances in  which  the  thoracic  duct  is 
compressed.  In  thoracic  aneurism  the 
distal  vessels  show  a  retarded  and  re- 
duced pulsation,  so  that  the  pulse  may 
be  weak  or  even  absent  from  the  one 
wrist. 


ANEURISM    (BABCOCK). 


673 


Case  of  aneurism  of  the  aortic  arch 
in  which  the  pulse  of  the  carotids  and 
right  radial  arteries  had  the  reversed 
character  of  the  pulsus  paradoxus. 
There  was  a  A'ery  marked  diminution 
in  the  volume  of  the  pulse  during 
expiration,  and  with  the  respiratory 
variations  there  was  a  definite  ana- 
crotic wave.  Post-mortem  examination 
showed  an  aneurism  involving  chiefly 
the  posterior  portion  of  the  aorta  in  the 
region  of  tliB  transverse  arch.  The  left 
carotid  and  innominate  arteries  sprang 
from  the  anterior  surface  of  the  arch 
instead  of  from  the  convexity,  on  ac- 
count of  the  distention  of  the  aorta. 
With  each  expiratory  excursion  these 
blood-vessels  were  compressed  against 
the  bony  thoracic  walls.  J.  Hay 
(Lancet,  April  27,  1901). 

In  the  course  of  their  studies  upon 
lesions  of  the  aorta  the  writers  have 
been  impressed  with  the  frequency  with 
which  some  of  the  lesser  signs  of  aortic 
aneurism  were  present.  Inequality  of 
the  pulse  was  present  in  10  out  of  18 
cases.  In  9  of  the  10  cases  pulsation 
was  more  vigorous  on  the  right  than 
on  the  left  side.  Inequality  of  the 
pupils  was  present  in  3  cases,  but  in  1  it 
might  have  been  due  to  nervous  com- 
plications. Suprasternal  pulsation  was 
present  in  12  cases  and  absent  in  6. 
Tracheal  tugging  of  distinct  downward 
character  was  present  in  11  and  absent 
in  7  cases.  A  systolic  thrill  was  felt  in 
the  vessels  of  the  neck  either  with  or 
without  slight  pressure  in  9  cases, 
and  it  could  not  be  elicited  in  9  cases. 
A  systolic  murmur  usually  transmitted 
into  the  vessels  of  the  neck  was  pres- 
ent in  11  cases,  but  was  not  heard  in 
7.  Twelve  of  the  cases  had  dyspnea; 
in  1  of  these  there  were  physical  signs 
of  emphysema  and  chronic  bronchitis  ; 
in  the  others  it  was  probably  due  to  the 
cardiac  condition.  J.  Sailer  and  G.  E. 
Pfahler  (Amer.  Jour.  Med.  Sci.,  Oct., 
1903). 

The  arterial  blood-pressure  in  most 
cases  of  aneurism  of  the  thoracic  aorta 
or  innominate  is  either  normal  or 
slightly  above  normal.  It  is,  as  a  rule, 
however,  much  higher  in  cases  of  mere 
dilatation   of   the   aorta,    and   this    fact 

1—43 


is  of  some  value  in  the  differential 
diagnosis  of  these  two  conditions. 
Williamson    (Lancet,  Nov.  30,   1907). 

In  examining  for  aneurism  of  the 
aorta,  one  should  carefully  percuss  the 
area  of  dullness  of  the  great  vessels, 
note  the  conduction  of  the  heart  sounds 
in  this  area,  examine  both  radial  pulses 
simultaneously,  examine  for  the  tra- 
cheal tug,  note  all  evidences  obtained 
by  inspection  or  palpation,  note  care- 
fully all  the  anatomical  relations  of  the 
aorta,  and  ever  keep  in  mind  the  pos- 
sibility of  aneurism.  The  early  symp- 
toms are  usually  pain  or  disturbance 
with  the  respiratory  apparatus,  the 
latter  from  pressure  on  air  passages  or 
the  recurrent  laryngeal  nerve.  The 
symptoms  often  simulate  those  of  heart 
disease.  There  are  no  pathognomonic 
signs;  the  features  may  be  entirely 
different  in  successive  cases.  Arnold 
(Amer.  Jour.  Med.  Sci.,  Apr.,  1908). 

Case  which  confirms  the  possibility 
of  a  disconnected  respiration  of  a  stac- 
cato type  from  the  hammering  of  the 
trachea  by  an  aneurism  resting  against 
it.  Ortner  (Med.  Klinik,  April  25, 
1909). 

In  cases  of  thoracic  aneurism,  delay 
or  increased  retardation  of  one  of  the 
radial  pulses  does  occur.  The  same 
delay  may  or  may  not  be  present  in  the 
case  of  the  corresponding  carotid  pulse. 
If  the  idea,  based  on  experimental 
physics,  be  correct,  that  delay  of  the 
pulse-wave  is  only  produced  as  the  re- 
sult of  the  wave  passing  through  the 
aneurism,  then  the  phenomenon  of  de- 
lay should  be  of  most  important  diag- 
nostic aid  in  the  localization  of  the 
aneurism.  Digital  examination  is  not  a 
reliable  test  of  the  presence  or  absence 
of  delay.  The  finger  may  miss  the 
delay  when  present,  and  may  diagnose 
it  when  absent.  A  more  delicate  in- 
strument, such  as  the  clinical  polygraph, 
is  necessary.  Leonard  Findlay  (Prac- 
titioner, Dec,  1909). 

Rupture  is  signalized  by  pain  of  sud- 
den onset  with  shock.  The  hemorrhage . 
may  escape  externally  through  the  skin, 
into  the  trachea,  or  into  the  alimentary 


674 


ANEURISM    (BABCOCK). 


canal;  if  into  the  pericardium  there  are 
evidences  of  acute  heart  compression; 
if  into  the  cavity  of  the  thorax,  of 
hematothorax ;  if  into  the  muscular 
substance,  the  formation  of  a  progress- 
ively enlarging  tumor.  The  rupture 
may  be  immediately  fatal,  or  the  pa- 
tient may  live  for  hours  or  for  days, 
and  repeated  or  continuous  leakage  may 
occur.  Rarely  does  recovery  follow- 
after  an  aneurism  of  one  of  the  great 
vessels  of  the  trunk  has  ruptured,  al- 
though the  patient  may  survive  for 
days  or  weeks. 

Case  of  abdominal  aortic  aneurism  in 
a    man    aged    41    years    in    whom    the 
writer    observed    several    hyperesthetic 
cutaneous  zones,  as  described  by  Head. 
Such   zones    are    segmental    regions    of 
the  body  corresponding  to  the  various 
viscera,    exactly    at   the    sensory   inner- 
vation   of    the    skin,    as    described    by 
Sherrington,  Starr,  Kocher,  and  Thor- 
burn.    Trophic  disturbances  occur  in  the 
skin  in  disease  of  the  arteries,  as,  for 
example,   in   zoster.     The  points  noted 
in    the    study   of   the    present    case    in- 
cluded the  belt-like  distribution  of  the 
radiations  of  pain  due  to  the  abdominal 
aneurism,  these  pains  dating  many  years 
before   the    development   of   the    symp- 
toms.    E.  Cedrangolo  (Riforma  medica, 
Mar.  23,  1907). 
COURSE. — Aneurisms  tend  to  pro- 
gressively   dilate    and    finally    to    rup- 
ture.    In  rare  instances  an  aneurismal 
sac  may   remain   stationary    for   many 
years,    finally    to    again    progressively 
dilate.      In   a   third    class    spontaneous 
cure  occurs  by  the  coagulation  of  blood 
within  the  sac,  which  may  completely 
consolidate  it,  with  or  without  oblitera- 
tion of  the  arterial  lumen.     Any  con- 
dition w^hich  interrupts  or  retards  the 
circulation  through  the  sac  may  favor 
this   spontaneous  cure.     This  termina- 
tion   at   times    is    followed   by   a    fatal 
gangrene   from  obstruction  of  the  col- 
lateral circulation. 


Plastic  arteritis  with  thrombosis  and 
obliteration  of  the  artery  may  also  lead 
to  a  cure.  More  frequently  the  aneu- 
rism progresses  to  rupture.  The  rup- 
ture may  occur  through  the  skin,  mu- 
cous membrane,  into  a  serous  or  syno- 
vial cavity  or  into  the  subcutaneous 
tissues,  muscles,  or  fascial  planes. 

There  may  be  repeated  moderate 
hemorrhages,  one  or  several  large  hem- 
orrhages, or  a  rapid  hemorrhage  suffi- 
cient to  cause  almost  instant  death 
or  a  progressively  increasing  hemor- 
rhagic edema  from  a  leaking  aneurism. 
This  may  lead  to  gangrene. 

Suppuration  of  an  aneurism  occurs 
most  frequently  in  the  axillary  region 
and  usually  results  from  the  formation 
of  an  abscess  adjacent  to  the  sac.  The 
sloughing  of  the  sac  wall  may  be  fol- 
lowed by  great  hemorrhage  as  the  ab- 
scess opens.  Rarely  does  a  plastic 
arteritis  produce  clotting  and  sponta- 
neous cure. 

DIFFERENTIAL  DIAGNOSIS. 
— The  expansile  pulsation,  bruit,  and 
retardation  of  the  distal  pulse  are 
fairly  characteristic  symptoms  of 
aneurism.  In  a  consolidated  aneu- 
rism, or  one  in  which  the  sac  has  been 
filled  by  clot,  these  signs  may  disap- 
pear. 

The  history  and  presence  of  a  firm 
mass  in  the  wall  of  the  blood-vessel  are 
suggestive.  Tumors  and  abscesses  ly- 
ing upon  large  arteries  may  pulsate, 
but  the  expansile  type  of  pulsation  is 
absent. 

When  the  skin  over  an  aneurism  has 
become  inflamed  the  condition  may 
closely  simulate  an  abscess,  so  that  only 
by  a  careful  study  of  the  patient  is  a 
correct  diagnosis  finally  to  be  made. 

Before  the  consolidation,  compression 
of  the  main  artery  proximal  to  the 
aneurism  may  produce  a  characteristic 


ANEURISM    (BABCOCK). 


675 


collapse  of  the  sac,  a  cessation  of  pul- 
sation, and  bruit,  changes  which  cannot 
be  produced  in  vascular  sarcomas  and 
other  tumors  which  may  simulate  aneu- 
risms. 

In  aneurisms  of  the  thorax  X-ray 
examinations  are  often  diagnostic. 

In  suspected  aneurisms  of  the  ab- 
dominal aorta  loss  or  retardation  of  the 
femoral  pulse  should  be  especially 
looked  for.  The  marked  pulsation  of 
the  undilated  aorta  in  thin  persons 
should  not  be  mistaken  for  aneurism. 

In  determining  the  compressibility 
of  the  aneurismal  sac  the  greatest  gen- 
tleness must  be  employed.  We  have 
observed  hemiplegia  to  promptly  follow 
the  examination  and  the  palpation  of 
a  carotid  aneurism  for  the  dislodgment 
of  particles  of  contained  clot. 

TREATMENT.  —  Dietetic,  hygi- 
enic, and  medicinal  measures  have 
been  used  since  antiquity  with  the  ob- 
ject of  slowing  the  circulation-  and  so 
simulating  coagulation  that  a  clot 
would  fill  the  sac.  The  ancient  method 
of  Valsalva  included  absolute  physical 
and  mental  rest,  a  very  limited  diet, 
with  the  deprivation  of  fluid,  and  re- 
peated venesections  continued  until  the 
patient  was  too  weak  to  lift  a  hand. 

The  more  recent  method  of  Tuff- 
nell's  was  less  severe,  although  rigor- 
ous; it  consisted  of  a  reduction  in  the 
diet  and  absolute  rest  in  a  horizontal 
position;  2  ounces  of  bread  and  butter 
are  given  for  breakfast  with  2  ounces 
of  milk;  3  ounces  of  bread  and  butter 
with  4  ounces  of  water  or  claret  for 
dinner;  2  ounces  of  bread  and  butter 
with  2  ounces  of  tea  for  supper.  A  fat 
diet  has  been  advised  by  Powell,  and 
the  use  of  meats  has  been  condemned. 

Cure  by  what  was  practically  the 
Tufnell  treatment.  It  consisted  of  as 
nearly  absolute  rest  as  possible,  re- 
stricted diet   for   a  week  and  later  an 


ordinary  fish  diet,  no  stimulation,  and 
potassium  iodide,  10  grains  three 
times  a  day.  The  dose  was  quickly 
and  steadily  increased  so  that  by  the 
end  of  the  third  week  60  grains  were 
being  taken  three  times  a  day,  with 
no  ill  effects  at  any  time.  As  a  local 
application  to  the  swelling,  collodion 
was  painted  all  over  the  surface  every 
night  and  morning.  Instead  of  con- 
tinuing his  previous  downward  prog- 
ress, he  commenced  to  improve  from 
almost  the  commencement  of  the  treat- 
ment, and  was  discharged  apparently 
cured  in  six  weeks.  Young  (Lancet, 
Sept.  22,  1906). 

Drugs  are  employed  to  reduce  the 
cardiac  frequency,  to  diminish  arte- 
rial tension,  and  increase  the  coagula- 
bility of  the  blood.  Potassium  iodide 
has  been  considered  to  be  the  most 
valuable  drug.  Ten  grains  three  times 
a  day  may  be  increased  until  40,  60, 
or  200  grains  three  times  daily  are 
administered,  according  to  the  degree 
of  tolerance.  It  is  especially  valuable 
in  syphilitic  patients. 

The  writer  reports  the  marked  suc- 
cess attending  the  treatment  of  an  in- 
teresting and  apparently  hopeless  case 
of  thoracic  aneurism  which  had  threat- 
ened to  rupture  externally.  The  skin 
covering  the  tumor,  which  was  located 
in  the  median  line  of  the  neck,  reaching 
from  the  level  of  the  lower  Iborder  of 
the  third  rib  to  just  above  the  level  of 
the  lower  border  of  the  thyroid  car- 
tilage, was  extremely  thin,  tense,  and 
shiny,  looking  like  an  abscess  on  the 
point  of  bursting.  The  patient  was 
put  to  bed  and  kept  absolutely  quiet. 
The  diet  was  restricted  as  far  as  pos- 
sible, and  all  stimulants  were  withheld. 
Iodide  of  potassium  was  administered 
internally,  in  doses  of  10  grains  three 
times  a  day,  the  dose  being  increased 
so  that  by  the  end  of  the  third  week 
60  grains  Mrere  being  taken  three  times 
a  day.  Collodion  was  painted  all  over 
the  surface  of  the  tumor  every  night 
and  morning.  The  patient  began  to 
improve  from  the  commencement  of  the 


676 


ANEURISM    (BABCOCK). 


treatment,  until  in  the  ninth  week  he 
was  well  enough  to  assist  in  the  work 
of  the  hospital  ward.  The  tumor  was 
very  much  smaller,  there  was  scarcely 
any  visible  expansile  pulsation,  and  the 
overlying  skin  was  normal.  The  pa- 
tient returned  to  his  work.  E.  E. 
Young  (Lancet,  Sept.  22,  1906). 

Three  cases  of  thoracic  aneurism 
treated  by  large  doses  of  potassium 
iodide  with  excellent  results.  In  2 
cases  there  was  apparent  recovery  with 
disappearance  of  the  pulsating  tumor 
and  the  bruit.  The  third  case  was  so 
far  advanced  that  external  hemorrhage 
had  taken  place  from  the  anterior  wall 
of  the  aneurism;  yet  on  80  grains  of 
potassium  iodide  three  times  a  day 
marked  improvement  took  place,  the 
patient  being  enabled  to  return  to  busi- 
ness and  to  lead  a  quiet  life.  Failure 
in  the  treatment  of  aneurism  with 
potassium  iodide  often  results  from  the 
fact  that  the  dose  is  too  small.  Sixty- 
grain  doses  ard*  necessary  in  bad  cases. 
Kingdon    (Lancet,  Aug.  22,  1903). 

To  increase  the  coagulability  of  the 
blood  in  the  treatment  of  saccular 
aneurisms  the  subcutaneous  injec- 
tions of  gelatin  were  first  recom- 
mended by  Lancereaux  and  Paulesco. 
One  or  2  Gm.  of  purest  gelatin  are 
dissolved  in  100  c.c.  of  decinormal  salt 
solution,  and  sterilized  by  heating  to 
the  boiling  point  for  one-half  hour  on 
five  successive  days.  Before  use  the 
gelatin  is  warmed  to  the  temperature 
of  the  body  and  100  c.c.  injected  under 
the  abdominal  skin  every  two,  three,  or 
four  days. 

The  injections  are  often  followed  by 
fever  and  pain.  The  possibility  of  ex- 
tensive coagulation  and  of  embolism 
has  not  been  demonstrated.  The  injec- 
tions may  cause  increase  of  vascular 
pressure  and  involve  rupture  of  a  large- 
sized  aneurism  whose  walls  are  thin. 
The  clinical  observations  so  far  made 
do  not  warrant  an  exact  estimate  of  the 
value  of  the  gelatin  treatment.  Henri 
Grenet  and  G.  Piquard  (Archives  gen- 
«rales  de  med.,  June,  1901). 


Pica  for  the  use  of  injections  of 
gelatin  in  aneurism  of  the  aorta.  The 
danger  of  tetanus  is  removed  if  the 
gelatin  is  properly  sterilized  and  no 
disagreeable  effects  are  noticed  by  the 
patients.  The  relief  of  pain  is  always 
very  prompt.  The  injections  may  be 
given  as  high  as  S  per  cent.,  although 
half  that  strength  is  usual.  Six  to  7 
ounces  are  injected  at  intervals  of  five 
or  six  days.  The  usual  formula  is  2j4 
per  cent,  gelatin  in  7  per  cent,  salt  solu- 
tion. Lancereaux  (Revue  de  therap.. 
No.   13,   1906). 

Case  of  large  traumatic  aneurism 
occupying  the  lower  half  of  the  left 
popliteal  space,  and  extending  down- 
ward to  a  line  about  6  inches  below  the 
knee-joint.  The  dilatation,  it  was 
thought,  involved  the  trunk  of  the 
posterior  tibial  artery  above  the  origin 
of  the  peroneal  branch,  and  also  the 
lower  part  of  the  popliteal  artery  above 
the  origin  of  the  anterior  tibial.  An 
attempt,  therefore,  to  extirpate  the  sac 
would  have  completely  abolished  the 
circulation  in  the  leg,  and  very  prob- 
ably resulted  in  gangrene.  After  a 
prolonged  and  careful  treatment  by 
rest  and  flexion  of  the  leg,  which 
proved  unsuccessful,  the  author  tried 
repeated  subcutaneous  injections  of 
sterilized  gelatin  serum.  Seven  injec- 
tions were  made,  the  intervals  varying 
from  seven  to  twenty  days.  After  five 
days  after  each  injection  the  aneurismal 
tumor  became  smaller  and  firmer.  The 
last  injection  was  followed  after  an 
interval  of  about  ten  days  by  complete 
cure.  Le  Dentu  (Bull,  et  mem.  de  la 
soc.  de  chir.  de  Paris,  No.  10,  1905). 

Several  cures  have  been  reported 
from  the  use  of  gelatin,  but  in  other 
instances  undesirable  thrombi  have 
formed  in  the  larger  veins,  while  teta- 
nus has  followed  the  use  of  imperfectly 
sterilized  gelatin.  Should  the  clot 
Avhich  forms  in  the  aneurismal  sac 
soften  and  be  absorbed,  the  gelatin  in- 
jections may  be  repeated  with  a  possi- 
bility of  good  eflfect. 

The  internal  administration  of  cal- 
cium chloride  and  the  subcutaneous 


ANEURISM    (BABCOCK). 


(i77 


injection  of  horse  serum  have  also 
been  used  to  increase  the  coagulabiHty 
of  tlic  blood. 

Case  of  aortic  aneurism  in  which  all 
the  symptoms,  except  a  slight  headache, 
had  disappeared  as  a  result  of  the  ad- 
ministration   of  calcium   chloride   for 
about  two  months.     The  calcium  chlo- 
ride was  given  three  times  daily.     The 
aneurism  was  clearly  visible  undeir  the 
X-ray.      Ambrose    (Jour.    Amer.    Med. 
Assoc,  Oct.  31,  1908). 
Arterial  Compression. — The  object 
of  this  method  is  to  so  slow  the  blood- 
current  within  the  sac  that  a  coagulum 
may  form.    The  pressure  may  be  prox- 
imal to  the  aneurism  and  be  carried  out 
by  means  of  a  pad,  tourniquet,  or  the 
pressure   of   the   thumbs   of   assistants 
acting  in  relay.     The  pressure  of  the 
thumb    is    reinforced    by    a    6-pound 
weight,  and  before  the  thumb  of  one 
assistant  is  removed  that  of  another  is 
properly  placed.    Each  assistant  serves 
for  fifteen  or  twenty  minutes,  and  the 
treatment  is  continued  for  from,  twenty- 
four  to  seventy-two  hours.  The  method 
by  compression  is  painful  and  when  in- 
strumental   may    cause    sloughing    or 
gangrene.     The  digital  compression  re- 
quires many  assistants  and  is  trouble- 
some, but  not  so  apt  to  cause  sloughing. 
The    compression    occasionally    cures, 
but  often  if  the  clot  is  deposited  it  is 
dissipated  before  organization  has  oc- 
curred. 

Three  cases  of  aneurism  followed, 
2  for  eight  years  and  1  for  four  years, 
in  2  of  which  permanent  cure  has  re- 
sulted from  treatment  based  on  a 
reduction  of  vascular  tension  below  the 
normal.  The  treatment  consists  in 
keeping  the  patient  at  rest  in  bed  and 
in  prescribing  a  diet  from  which  soups 
containing  an  excess  of  fat;  meats,  es- 
pecially those  cooked  rare ;  game,  fish, 
cheese,  salted  foods,  tea,  coffee,  spirits, 
heavy  beers,  and  an  excess  of  wine 
are  eliminated.  Tobacco  is  also  for- 
bidden.    Drugs,  such  as  nitroglycerin 


and  sodium  nitrite,  were  adrninistered. 
The  iodides  have  been  overrated  in 
this  connection.  In  syphilitic  aneu- 
risms mercurial  injections  are  dan- 
gerous on  acQOunt  of  their  liability 
to  affect  the  kidneys,  and,  as  a  conse- 
quence, to  cause  increased  arterial  ten- 
sion. The  milk  diet  in  connection 
with  theobromine,  which  assists  in 
eliminating  vasoconstrictor  poisons, 
is  very  helpful  in  reducing  vascular 
tension.  H.  Huchard  (Jour,  des 
praticiens,  Nu.  20,  p.  307,  1906). 

Forced  flexion  of  the  elbow  and 
knee,  the  part  being  held  by  a  bandage 
with  the  pad  at  the  flexure,  has  been 
employed  for  small  aneurisms  of  the 
extremities.  The  position  is  uncom- 
fortable and  the  method  of  little  ad- 
vantage over  other  methods  of  com- 
pression. 

The  isolation  of  a  mass  of  blood 
within  the  aneurismal  sac  by  the  ap- 
plication of  an  Esmarch  bandage  be- 
low and  above  the  aneurismal  sac, 
while  efficient  in  causing  clotting,  has 
led  to  gangrene  of  the  extremity,  and 
the  method  has  been  abandoned.  It 
has  been  advised  that  an  Esmarch 
bandage  be  applied  for  one  and  one- 
half  hours  and  then  removed,  with  con- 
tinuous light  compression  of  the  artery 
above  the  aneurism  for  several  days. 
Apart  from  the  danger  of  compression, 
another  danger  of  these  methods  is  in 
the  completeness  of  the  coagulation, 
which  may  extend  into  the  collateral 
vessels  and  so  destroy  their  function 
that  gangrene  follows. 

Arterial  Ligature. — Ligature  of  the 
main  artery  just  above  the  sac  is  espe- 
cially efficient  in  interrupting  the  circu- 
lation. This  is  Anel's  operation,  but 
was  modified  by  John  Hunter,  who 
placed  the  ligature  at  a  distance  above 
the  sac,  where  he  supposed  that  the 
arterial  walls  were  healthier.  Anel's 
operation  is  now  preferred  to  Hunter's. 


678 


ANEURISM    (BABCOCK). 


The  most  important  part  of  the  new 
surgical  work  with  blood-vessels,  espe- 
cially with  aneurism,  depends  upon  the 
similarity  of  the  serous  coat  of  blood- 
vessels to  the  peritoneum.  Like  the 
latter,  the  former  throw  out  lymph  for 
purposes  of  repair.  Irritated  surfaces 
in  apposition  adhere,  and  septic  proc- 
esses in  the  serous  coat  cause  changes 
similar  to  those  which  occur  in  the 
peritoneum.  Torsion  of  blood-vessels 
also  causes  quick  plastic  occlusion  that 
arteries  of  the  third  class  may  be  thus 
treated  in  place  of  by  ligation.  Aneu- 
rism treated  by  digital  pressure,  by 
the  introduction  of  coils  of  wire,  or 
by  electric  needles  causes  exudation 
of  lymph  from  the  serous  coats,  fol- 
lowed by  adhesion  of  apposed  sur- 
faces. .  The  new  work  in  suturing 
blood-vessels  depends  for  its  safety 
upon  the  prompt  plastic  repair  of  the 
serous  coats.  Morris  (Annals  of 
Surg.,  July,  1908). 

When  on  account  of  anatomical  con- 
ditions the  Hgature  cannot  be  placed 
above  the  sac  the  method  of  distal  li- 
gation, such  as  Basedow's,  in  which 
the  main  vessel  is  ligatured,  or  War- 
drop's,  in  which  one  or  more  of  the 
chief  branches  is  secured  as  by  ligation 
of  the  right  subclavian  for  aneurism  of 
the  innominate  artery,  may  be  tried. 
Rarely  are  they  efficient. 

Case  in  which  ligation  of  the  ab- 
dominal aorta  was  performed  for  dis- 
secting aneurism  involving  the  wall 
of  the  aorta  from  the  celiac  axis  to 
the  mesenteric  vessels.  This  makes 
the  fourteenth  recorded  operation  in 
which  the  aorta  has  been  ligatured.  So 
far  they  have  all  proved  fatal,  but  this 
case  is  encouraging,  as  showing  that 
there  is  no  inherent  reason  why  suc- 
cess should  not  yet  be  attained.  For 
two  days  the  patient  did  very  well,  but 
on  the  third  day  she  showed  signs  of 
intense  septicemia,  and  she  died  fifty- 
three  hours  after  operation.  On  post- 
mortem examination,  it  was  found  that 
the  septicemia  was  due  to  gangrene  of 
small  portions  of  the  bowel,  which  had 
lain   in   contact   with   the    forceps   used 


to  clamp  the  ligature.  The  aneurism 
was  found  to  be  full  of  blood-clot, 
while  the  aorta  remained  patent.  An 
embolus  was  found  in  the  left  internal 
iliac.  The  case  demonstrates  that  an 
aneurism  of  the  aorta  can  be  made  to 
fill  with  clots  by  the  application  of  a 
temporary  ligature  to  the  aorta,  and 
that  circulation  in  the  extremities  may 
be  re-established  on  removal  of  the 
ligature.  R.  P.  Morris  (Annals  of 
Surg.,  Feb.,  1900). 

Ligation  of  abdominal  aorta  has 
been  done  14  times  to  relieve  a  pe- 
ripheral aneurism.  It  makes  great 
demands  on  the  heart  and  has  never 
been  successful.  Collateral  circula- 
tion soon  developed,  annulling  the 
benefits  of  the  ligation.  The  great 
number  of  Q.ommunications  wnth  the 
general  circulation  render  the  estab- 
lishment of  collateral  circulation 
inevitable.  Its  development,  how- 
ever, requires  extra  work  on  the 
part  of  the  heart,  thus  inducing  con- 
siderable hypertrophy.  In  the  absence 
of  general  atheromatosis  of  the  vessels 
and  if  the  operation  is  technically  pos- 
sible, extirpation  of  the  aneurism  may 
be  successful.  In  10  of  the  14  cases 
on  record  death  was  the  direct  result 
of  the  operation.  Katzenstein  (Archiv 
f.  klin.  Chir.,  Bd.  Ixxvi,  Nu.  3,  1905). 

A    successful    case     (the    ninth    with 
recovery)    of   ligation   of   the   innom- 
inate    artery.      The     patient    was    a 
colored  man   aged  27  suffering  from 
subclavian  aneurism;  the  innominate 
only    was    tied    with    a    largest-sized 
braided    silk    ligature    in    a    "granny" 
knot    drawn    just    tightly    enough    to 
approximate  the  vessel  walls,  but  not 
to  crush  its  coats.    The  ligature  came 
away  fifty-one  days  after  the  opera- 
tion   while     the    wound    was     being 
dressed;  the  recovery  was  good  prac- 
tically in  twenty  days.     W.  B.  Burns 
(Jour.   Amer.    Med.   Assoc,   Nov.    14, 
1908). 
Dix's  Operation. — The  artery  is  ex- 
posed   and    encircled    by    a    strand    of 
silver  wire.     The  ends  of  the  wire  are 
brought  through  the  tissues  to  one  side 
of  the  wound,  and  are  twisted  over  a 


ANEURISM    (BABCOCK). 


679 


split  cork  until  pulsation  ceases  in  the 
aneurism.  Later  slight  pulsation  re- 
turns to  the  sac,  and  after  two  or  three 
clays  the  wire  is  tightened  hy  i)lacing 
wedges  under  the  loop.  Ahout  the  fifth 
or  sixth  day  the  wire  is  cut  and  re- 
moved. 

Excision  of  the  Sac  and  Implanta- 
tion.— The  interposition  of  a  segment 
of  an  adjacent  vein  has  also  been  tried, 
but  the  procedure  has  rarely  been  suc- 
cessful. 

Removal  or  Obliteration  of  the  Sac. 
— The  ancient  method  of  Antyllus,  in 
which  the  sac  was  dissected  out  or 
opened  and  packed,  has  been  suc- 
ceeded by  the  modern  obliterative 
method  of  Matas.  In  this  operation 
the  patient  is  anesthetized,  a  tourniquet 
applied,  the  sac  is  opened  by  a  longi- 
tudinal incision,  emptied,  and  the  mouth 
of  each  vessel  is  exposed  within  the 
sac  and  sutured  from  the  inside  by 
separate  silk  or  chromicized  catgut 
sutures.  The  redundant  w^alls  of  the 
sac  are  then  so  enfolded  and  sutured  as 
to  form  a  solid  pad  under  the  skin.  The 
advantage  of  this  method  lies  in  the  fact 
that  the  sac  is  not  loosened  from  the 
adjacent  tissues,  and,  therefore,  there 
is  little  risk  of  injuring  adjacent  col- 
lateral nerves  and  veins. 

Matas's  method  combines  the  ad- 
vantages of  ligation  and  excision, 
while  at  the  same  time  it  is  easier, 
safer,  and  may  be  more  conservative. 
It  is  suitable  both  in  the  fusiform  and 
sacculated  types  of  the  disease.  After 
applying  a  constrictor  above  the  site  of 
the  disease,  if  in  a  limb,  or  temporarily 
ligating  the  proximal  and  distal  trunks, 
if  the  carotid  is  the  vessel  at  fault,  the 
operator  cuts  into  the  sac,  thoroughly 
removes  the  contained  clots,  rubs  the 
serosa  with  gauze,  and  proceeds  to  in- 
sert sutures.  The  sutures,  preferably 
catgut,  are  first  applied  to  the  openings 
of  all  vessels  entering  or  leaving  the 
sac;   then   the   deeper   portions   of   the 


sac  are  closed  by  two  rows  of  contin- 
uous Lembert  sutures.  The  clastic  con- 
strictor is  now  removed,  and  if  any 
blood  escapes  one  or  two  points  of 
suture  are  inserted  to  control  this.  The 
next  step  consists  in  folding  the  excess 
of  sac  wall  on  itself,  and  in  so  doing 
inverting  the  edges  of  the  skin  wound. 
The  operation  thus  performed  has  been 
very  successful,  and  in  some  cases  of 
sacculated  aneurism  the  circulation  may 
be  re-established  through  the  repaired 
vessel.  Binnie  (Jour.  Amer.  Med. 
Assoc,  June  25,  1904). 

Two  cases  of  fusiform  aneurism 
rupturing  into  the  surrounding  tissue 
and  treated  by  the  writer  by  Matas's 
method  of  suturing  the  leading  open- 
ings within  the  aneurismal  sac.  In 
neither  case  was  the  sac  obliterated, 
but  drainage  was  employed  and  the  re- 
sults were  satisfactory.  In  one  of  his 
cases  to  have  sufired  together  the 
walls  of  the  cavity  would  have  required 
a  14-inch  incision.  It  is  better  in  such 
cases  to  close  the  incision  partly  and 
to  drain,  allowing  the  cavity  to  fill  up 
by  granulation,  instead  of  closing  it  by 
suture,  as  is  done  in  the  unruptured 
cases.  J.  A.  Danna  (Jour.  Amer.  Med. 
Assoc,  Aug.  5,  1905). 

Matas's  method  approaches  nearer 
the  ideal  for  the  cure  of  aneurism  than 
any  other,  and  is  more  generally  appli- 
cable. It  can  be  employed  in  every 
accessible  variety  in  which  the  circula- 
tion can  be  temporarily  controlled,  and 
it  interferes  less  than  any  other  with 
the  blood-supply  beyond  the  aneurism. 
The  experimental  work  of  various  sur- 
geons shows  the  possibilities  of  vas- 
cular surgery,  suture,  anastomosism 
transplantation,  substitution  of  vein  for 
artery,  arteriotomy  for  embolism  hav- 
ing all  been  found  practicable.  The 
operation  of  Matas  was  based  upon  the 
fact  that  when  intima  is  approximated 
to  intima  union  occurs,  and,  hence,  that 
an  aneurism  could  be  cured  by  closing 
the  mouths  of  the  vessels  entering  it 
and  obliterating  the  sac  by  approximat- 
ing its  walls.  Gibbon  (Annals  of  Surg., 
Sept.,  1907). 

Results  of  endoaneurismorrhaphy 
(the  writer's  method)   in  85  operations 


680 


ANEURISM    (BABCOCK). 


by  52  surgeons  up  to  the  present  date. 
The  legitimate  mortality  of  the  opera- 
tion itself  was  2.3  per  cent.;  of  second- 
ary hemorrhage,  2.3  per  cent. ;  of 
gangrene,  4.6  per  cent.  Eliminating  3 
of  the  gangrene  cases  in  which  there 
was  simultaneous  injury  and  ligation 
of  veins  or  secondary  ligature  of  an 
artery,  the  percentage  of  this  accident 
is  1.1  only.  The  total  of  postoperative 
deaths  from  all  causes  was  7  to  78 
recoveries.  The  percentage  of  relapses, 
which  occurred  only  in  the  reconstruct- 
ive operations  (4  in  13,  or  28  per 
cent.),  was  only  4.7  per  cent,  to  the 
total.  The  author  believes  that  the 
fundamental  principle  on  which  the 
operation  is  based,  viz.,  that  the  endo- 
thelial lining  of  the  vascular  system 
which  is  continued  in  the  aneurismal 
sac  is  analogous  in  its  pathological  be- 
havior to  the  reactions  and  reparative 
processes  which  occur  in  the  endothelial 
surfaces  of  the  other  serosa,  such  as 
the  peritoneum  and  the  pleura,  has  been 
absolutely  confirmed  by  the  experience 
in  these  85  cases.  They  have  also  dis- 
proved Scarpe's  law  that  complete  ob- 
literation of  the  vessel  is  a;n  essential 
to  the  cure,  which  result  is  also  sup- 
ported by  the  facts  of  the  suture  and 
repair  of  arteries.  An  important  point 
of  the  technique  is  the  prophylactic 
hemostasis,  which  must  be  made  abso- 
lute, and  the  problem  increases  in  com- 
plexity and  difficulty  the  higher  the 
operation,  and  the  writer  mentions  the 
methods  and  appliances  for  this  pur- 
pose. Experience  demonstrates  that  in 
all  sacciform  aneurisms  with  a  single 
orifice  of  communication  the  closure  of 
this  orifice  by  suture  without  interfer- 
ing with  the  lumen  or  the  capacity  of 
the  vessel  is  to  be  looked  on  as  obliga- 
tory. The  indication  for  the  recon- 
structive operation,  however,  is  fusi- 
form aneurism  with  separate  orifices  of 
entrance  and  exit,  and  must  still  be  con- 
sidered sub  j'udice.  In  the  vast  major- 
ity of  cases  of  aneurism  of  the  ex- 
tremities the  simple  obliterative  pro- 
cedure proved  satisfactory.  It  gives  a 
cure  with  less  risk  to  the  distal  parts 
than  either  the  ligature  or  the  method 
of  extirpation.     The  indications  in  any 


given  case  will  not  be  entirely  satisfac- 
tory until  we  have  a  sure  clinical  proof 
of  the  adequacy  of  the  collateral  cir- 
culation. Korotkow's  method  of  testing 
the  most  peripheral  blood-pressure  may 
be  the  solution*  of  the  problem.  R. 
Matas  (Jour.  Amer.  Med.  Assoc,  Nov. 
14,   1908). 

The  advantages  of  Matas's  endo- 
aneurismorrhaphy  are  as  follows:  It 
is  more  radical  in  its  effects  than  liga- 
ture and  extirpation ;  it  is  free  from 
risk  of  injury;  it  is  only  exceptionally 
followed  by  gangrene ;  it  does  not  in- 
terfere with  the  collateral  circulation ; 
it  prevents  any  danger  of  injury  of  a 
vein,  and  is  applicable  to  cases  in 
which  extirpation  is  no  longer  possible. 
For  suture  chromicized  catgut  or  fine 
silk  is  employed.  The  method  is  chiefly 
indicated  in  cases  in  which  provisional 
hemostasis  can  be  carried  out  and 
where  the  aneurismal  sac  is  accessible. 
Altogether  149  cases  have  been  re- 
ported, in  131  of  which  the  lower  ex- 
tremity was  affected.  Among  the  last 
64  cases  there  have  been  no  deaths,  no 
recurrences  or  secondary  bleeding,  and 
only  one  instance  in  which  gangrene 
occurred  as  a  complication.  F.  Gardner 
(Gaz.  d.  Hop.,  No.  118,  1910). 

A  second  method  is  Matas's  con- 
servative   endoaneurismorrhaphy,    to 

be  used  for  sacculated  aneurisms  open- 
ing by  a  narrow  mouth  into  the  main 
vessel.  This  opening  is  sutured  from 
the  inside  of  the  sac  and  the  wound 
reinforced,  pleating  and  suturing  the 
overlying  sac.  In  reconstructive  endo- 
aneurismorrhaphy an  attempt  is  made 
to  restore  the  normal  lumen  of  the 
artery  in  a  fusiform  aneurism.  A  rub- 
ber tube  may  be  temporarily  introduced 
as  a  guide  between  the  afferent  and 
efferent  mouth  of  the  sac,  and  the  walls 
of  the  sac  so  sutured  as  to  restore  a 
canal  having  the  lumen  similar  to  that 
of  the  adjacent  artery.  This  line  of 
suture  is  likewise  to  be  reinforced  by 
pleating  and  suturing  the  redundant 
walls  of  the  sac. 


ANEURISM    (BABCOCK). 


681 


Temporary  partial  obliteration  of 
the  main  artery  by  use  of  metallic 
rings  or  clips;  Halstead  and  others 
have  devised  rings  or  clips  composed 
of  aluminum  or  other  metal  which  may 
be  applied  to  an  arterial  trunk  in  such 
a  manner  that  the  lumen  in  the  vessel 
is  reduced  or  obliterated.  By  reducing 
the  lumen  the  current  in  the  artery  and 
sac  distal  to  the  ring  may  be  so  slowed 
as  to  favor  curative  coagulation,  and 
if  properly  applied  it  has  been  found 
that  these  rings  are  well  tolerated  by 
the  arterial  wall,  and  have  not  the  same 
tendency  to  ulcerate  into  the  lumen  of 
the  vessel  as  a  hgature. 

The  pain  of  an  abdominal  aneurism 
may  be  greatly  lessened  and  its  growth 
checked  by  the  application  of  a  partially 
occluded  metallic  band  to  the  aorta, 
proximal  to  the  aneurism.  When  the 
aneurism  is  saccular  and  gives  origin 
to  no  important  vessels  a  cure  is  pos- 
sible by  this  means.  When  the  band 
produces  an  anemia  of  the  kidneys, 
there  appear  for  a  time  large  numbers 
of  waxy  casts  in  the  urine.  Gatch 
(Annals  of  Surg.,  July,  1911). 

The  application  of  a  ligature  is  not 
feasible  in  the  case  of  the  aorta,  for 
in  every  case  in  which  a  ligature  has 
been  employed  the  patient  has  died,  if 
not  from  the  immediate  danger  from 
the  operation,  then  some  days  or  weeks 
later  from  secondary  hemorrhage  due 
to  the  ligature  cutting  its  way  through 
the  wall  of  the  artery. 

Macewen's  Acupuncture.  —  This 
method  aims  to  scarify  the  lining  of 
the  sac  so  that  the  granulations  form 
upon  which  the  blood  may  coagulate. 
One  or  more  long  fine-silk  needles  are 
thrust  into  the  aneurism  so  that  their 
points  just  touch  the  opposite  wall.  The 
pulsatile  movements  of  the ,  sac  wall 
cause  the  needle-points  to  scratch  the 
lining  of  the  sac.  The  needles  may  be 
left  in  place  for  some  hours,  attempts 


being  made  to  so  change  their  position 
that  as  large  an  area  as  possible  of  the 
lining  will  be  abraded.  The  method  is 
of  very  limited  value. 

Electrolysis  increases  the  efficiency 
of  Macewen's  method.  Insulated  nee- 
dles are  passed  and  a  galvanic  current 
from  20  to  30  milliamperes.  Needles 
should  be  permitted  to  touch  the  oppo- 
site wall  of  the  sac  so  as  to  produce 
the  delicate  abrasion  as  in  acupuncture. 

Moore's  method  consists  in  the  use 
of  a  delicate  wire  so  tempered  as  to 
coil  within  the  sac,  where  it  is  permitted 
to  remain  permanently.  A  small,  hol- 
low needle  is  introduced  into  the  sac 
until  the  blood  flows  and  from  5 
to  20  feet  of  wire,  according  to  the; 
size  of  the  sac,  passed  through  the 
needle.  The  end  of  the  wire  is  then 
pushed  through  the  needle  or  cut  close 
to  the  skin  and  made  to  imbed  itself. 

The  Moore-Corrady  method  con- 
sists in  passing  the  current  from 
20  to  80  milliamperes  through  the  coil 
of  wire  which  has  been  introduced  into 
the  sac.  A  wire  of  fine  drawn  gold  is 
preferred,  and  from  5  to  20  feet  intro- 
duced, as  in  the  Moore  method.  The 
current  is  permitted  to  flow  about  one 
hour,  negative  pole  being  connected 
with  a  pad  upon  the  patient's  abdomen 
or  back.  The  wire  is  permitted  to  re- 
main permanently  within  the  sac. 

Aneurism  of  the  left  subclavian 
artery  in  which  20  feet  of  gold  wire 
were  introduced  into  the  sac  through  a 
hollow  needle,  and  a  galvanic  current, 
gradually  increasing  from  1  to  80  milli- 
amperes, was  employed  for  about  one 
hundred  and  ten  minutes.  The  pulsa- 
tion and  size  of  the  tumor  temporarily 
decreased  and  afterward  increased,  and 
death  occurred  on  the  twentieth  day 
after  operation,  due  to  exhaustion  pro- 
duced by  long-continued  pain,  and 
hastened  by  the  formation  of  a  throm- 
bus in  the  left  common  carotid  artery, 


682 


ANEURISM    (BABCOCK). 


caused  by  the  pressure  of  the  aneurism. 
The  necropsy  showed  a  cocoanut-shaped 
aneurism  involving  the  entire  length  of 
the  artery.  Its  cavity  was  occupied  in 
large  part  by  a  clot  in  varying  stages 
of  organization,  through  which  the  wire 
was  well  distributed.  This  operation 
is  worthy  of  trial  when  medical  treat- 
ment fails.  The  percentage  of  success 
will  be  greatly  increased  if  the  opera- 
tion be  not  performed  as  a  last  resort. 
Daland  (Penna.  Med.  Jour.,  Dec, 
1903). 

These  methods  have  chiefly  been  em- 
ployed for  aneurisms  of  the  thoracic 
aorta.  Occasionally  cures  are  reported, 
but  failures  are  frequent  and  fatal  acci- 
dents have  occurred.  It  is  obvious  that 
even  in  so-called  cures  the  patient's 
ultimate  condition  is  not  a  normal  one. 
Sterilized  horsehair,  silk,  and  catgut 
have  also  been  tried,  but  with  question- 
able benefit. 

A  recent  addition  to  the  methods  of 
treatment  is  that  of  Abrams,  which, 
though  qualified  by  him  as  palliative, 
seems  to  have  produced  lasting  bene- 
ficial effects  in  a  large  number  (40)  of 
his  cases.  It  consists  of  repeated  con- 
cussions over  the  seventh  cervical 
vertebra,  which  are  thought  by 
Abrams  to  cause,  through  the  vascc 
motor  system,  contraction  of  the 
diseased  vascular  area.  Confirmatory 
evidence  is  still  too  scant  to  warrant 
any  opinion  as  to  the  actual  value  of 
this  method. 

A.  Abrams,  of  San  Francisco,  claims 
that  the  subsidiary  center  of  the  vaso- 
constrictor nerves  of  the  aorta  is  located 
in  the  spinal  cord  in  proximity  to  the 
spinous  process  of  the  seventh  cervical 
vertebra,  and  that  by  stimulation  of  the 
center  in  question  by  concussion  the 
normal  as  well  as  the  abnormal  aorta 
may  be  brought  to  contraction.  Ample 
evidence. is  furnished  of  the  latter  fact 
in  his  work  on  spondylotherapy.  The 
method,  in  brief,  which  he  suggests  in 
the  treatment  of  aortic  aneurism  con- 


sists in  concussion  of  the  spinous 
process  of  the  seventh  cervical  verte- 
bra. He  deprecates  the  employment 
of  the  conventional  vibrating  appa- 
ratus. The  vibratory  apparatus  which 
the  physician  must  employ  is  one 
giving  the  percussion  stroke.  All 
other  motions,  such  as  oscillations, 
shaking,  and  friction,  interfere  with 
results.  In  the  absence  of  a  suitable 
apparatus,  a  pleximeter  (a  strip  of 
linoleum  or  thick  rubber)  and  a 
hammer,  to  the  end  of  which  is  fixed 
a  piece  of  hard  rubber,  are  employed. 
The  pleximeter  is  applied  to  the 
seventh  cervical  spine  and  is  struck 
a  series  of  rapid  and  moderate  blows 
by  the  hammer.  The  daily  seances, 
according  to  results,  may  last  from  five 
to  fifteen  minutes,  but  during  the  seance 
the  treatment  must  be  interrupted  from 
time  to  time  to  avoid  irritations  of  the 
skin. 

The  results  of  Abrams's  method  are 
usually  immediate,  great  relief  follow- 
ing a  few  seances.  When  the  writer 
first  encountered  the  monograph  of  the 
latter  on  the  subject,  he  was  rather 
skeptical,  although  Abrams  anticipates 
such  criticism  in  his  book  by  observing 
that  any  merit  attached  to  his  method 
may  be  obscured  by  its  simplicity. 

The  writer  presents  the  history  of  a 
personal  case  suffering  from  aneurism 
of  the  thoracic  aorta  which  was  treated 
successfully  by  the  "concussion  method" 
of  Abrams.  The  aneurism  had  per- 
forated the  chest  wall.  Within  one 
week  all  the  symptoms  had  disappeared, 
and  fourteen  months  after  the  patient's 
discharge  he  was  as  well  as  when  dis- 
missed. L.  St.  John  Hely  (Amer.  Jour, 
of  Physiol.  Therap.,  July,  1910). 

Case  of  aneurism  of  the  thoracic 
aorta  treated  by  Abrams's  method. 
After  the  first  daily  seance  of  concus- 
sion, lasting  ten  minutes,  the  systolic 
murmur  over  the  aorta  almost  disap- 
peared. Three  days  later  the  aneuris- 
mal  dullness  measured  transversely  2.6 
cm.  After  two  more  days  the  aneurism 
measured  2  cm.  and  the  patient's  weight 
was  123  pounds,  an  increase  of  5 
pounds.  Two  days  later  there  was 
absolutely  no  dullness  over  the  site  of 


ANEURISM    (BABCOCK). 


683 


the  aneurism,  the  pains  in  the  chest 
were  gone,  expectoration  was  reduced 
about  50  per  cent.,  but  the  cough  con- 
tinued with  less  frequency  and  severity. 
After  about  two  months  the  patient's 
weight  was  135  pounds.  He  had  abso- 
lutely no  symptom  beyond  an  occasional 
slight  couiih.  TurnbuU  (Med.  Record, 
Sept.  9,  1911). 

Report  of  a  case  of  aneurism  of  the 
thoracic  aorta  treated  successfully  by 
Abrams's  method.  There  was  no 
X-ray  verification  of  the  condition  in 
this  case,  but  the  physical  signs  re- 
specting the  aneurism  and  the  results 
of  treatment  were  absolutely  positive 
and  unmistakable.  L.  C.  Boyd  (N.  Y. 
Med.  Jour.,  Oct.  21,  1911). 

ARTERIOVENOUS  ANEU- 
RISM.— These  conditions,  termed  by 
Hunter  aneurism  by  anastomosis,  are 
characterized  by  an  arteriovenous  fis- 
tula. They  may  be  divided  into  two 
chief  forms : — 

(a)  Aneurismal  varix  is  character- 
ized by  the  direct  communication  of  the 
artery  with  the  vein.  The  blood-pres- 
sure is  much  higher  in  the  artery ;  the 
arterial  flow  is  forced  into  the  vein, 
which  becomes  thickened,  dilated,  sac- 
culated, and  tortuous.  The  condition 
is  usually  due  to  the  incised  wound  in- 
volving the  contigous  walls  of  an  artery 
and  vein,  and  gunshot  wounds.  Occa- 
sionally they  result  from  contusions 
without  external  wound,  and  may  even 
develop  spontaneously.  In  the  older 
days  the  common  cause  was  phlebot- 
omy. In  order  of  frequency  the  bra- 
chial, femoral,  popliteal,  carotid,  tem- 
poral, subclavian,  and  axillary  arteries 
are  involved.  Instances  are  recorded 
in  which  the  condition  has  spontane- 
ously occurred  in  connection  with  the 
abdominal  and  thoracic  aorta,  and  after 
gunshot  wounds  of  the  head  a  fistula 
may  form  between  the  cavernous  sinus 
and  internal  carotid  artery. 

(b)  Varicose  Aneurism. — The  vein 


commttnicates  with  the  artery  through 
the  medium  of  an  aneurismal  sac.  This 
usually  develops  from  a  traumatic  aneu- 
rism which  becomes  adherent  to  an 
adjacent  vein  and  finally  opens  into  it. 
Both  the  artery  and  the  vein  may  be 
injured  simultaneously  and  an  interme- 
diate blood-clot  first  form,  the  sac 
finally  replacing  the  area  occupied  by 
the  blood-clot.  Such  an  aneurism  may 
form  at  the  ends  of  the  divided  vessels 
in  an  amputation  stump. 

An  arteriovenous  aneurism  with  an 
arterial  sac,  such  as  that  developed 
from  the  erosion  of  a  true  aneurism 
through  the  wall  of  an  adjacent  vein,  is 
rare,  and  has  been  classified  as  a  third 
variety  of  arteriovenous  aneurism. 

Symptoms.— A  marked  pulsation 
which  is  communicated  widely  to  the 
communicating  veins  is  present  and', 
usually  associated  with  a  loud,  whistling 
bruit.  The  bruit  is  both  systolic  and 
diastolic.  The  thrill  may  be  palpable. 
The  interference  with  the  normal  circu- 
lation in  the  vein  may  produce  stagna- 
tion, local  cyanosis,  pigmentation,  ec- 
zema, elephantiasis,  muscular  atrophy, 
ulceration,  rarely  gangrene.  The  pres- 
sure upon  the  nerves  may  result  in 
paresthesia  or  paralysis. 

Treatment. — The  treatment  of  ar- 
teriovenous aneurism  is  usually  op- 
erative, as  the  disease  is  usually  per- 
sistent and  progressive.  The  artery 
may  be  clamped  above  and  below  the 
opening  and  the  opening  in  the  artery 
and  vein  closed  by  arterial  suture. 
Where  a  thoracic  aneurism  is  present 
the  sac  may  be  split  and  the  communi- 
cating opening  sutured  from  within  the 
sac,  as  in  Matas's  aneurismorrhaphy.  In 
some  cases  it  may  be  necessary  to  ligate 
the  artery  above  and  below  the  point  of 
communication.  As  a  rule,  the  vein 
should  not  be  ligatured. 


684 


ANGINA  PECTORIS    (VICKERY). 


In  small  traumiatic  aneurisms  in 
which  the  distended  inner  coat  of  the 
vessel  bulged  through  the  external 
coats  we  have  found  it  possible  to  re- 
duce the  hernia-like  protrusion  and  to 
reunite  the  median  adventitia  by  fine 
silk  sutures,  which  reinforce  the  union 
by  suturing  adjacent  connective  tissue 
to  the  arterial  wall. 

The  difficulties  which  accompany  the 
operative  treatment  of  arteriovenous 
aneurisms  of  the  subclavian  artery  are 
very  great.  It  is  not  easy  to  work 
under  the  subclavian  in  the  presence  of 
an  hematoma.  In  4  of  the  cases  the 
clavicle  was  resected.  The  effect  upon 
the  arm  of  the  diseased  side  when  de- 
prived of  the  support  of  the  clavicle 
and  of  the  blood-supply  from  its  artery 
and  vein  must  be  considered.  Another 
difficulty  consists  in  the  size  of  the 
vessels  and  in  their  situation.  Hemor- 
rhage is  of  grave  significance,  on  ac- 
count of  its  profuseness,  its  frequency, 
and  its  depth.  In  3  of  the  cases  the 
sac  was  opened  in  order  to  attach 
hemostatic  forceps.  In  this  location, 
one  should  also  fear  the  entrance  of 
air  into  the  veins.  The  radical  opera- 
tion ought,  therefore,  to  be  rejected  as 
an  operation  of  choice,  on  account  of 
the  dangers  of  the  operation.  Even  if 
the  operation  should  not  restilt  fatally, 
the  subsequent  condition  of  the  patient 
may  be  a  distressing  one,  as  it  was  in 
2  of  the  4  patients  who  recovered. 
Pluyette  and  Bruneau  (Revue  de  chir., 
July,  1905). 

Analysis  of  161  cases  of  arteriovenous 
aneurisms  published  since  1889.  The 
femoral  was  involved  in  80  and  the 
popliteal  in  35  cases.  Much  better  re- 
sults are  obtainable,  as  a  rule,  from 
operating  directly  on  the  sac  than  from 
ligatures.  The  main  drawback  to  a 
complete  cure  is  the  frequent  coexist- 
ence of  nervous  lesions  complicating 
the  aneurism,  which  are  generally  solely 
responsible  for  the  postoperative  dis- 
turbances. Only  when  direct  action  on 
the  sac  is  impossible  should  ligatures 
be  given  the  preference.  Removal  of 
the  sac  offers  the  same  advantages  over 


incision  for  the  arteriovenous  as  for 
the  arterial  aneurisms.  Monod  and 
Vanverts  (Revue  de  chir.,  Oct.,  1910). 

Conditions  related  to  aneurisms  in- 
clude certain  nevi,  cavernous  angi- 
oma, aneurism  by  anastomosis,  and 
arterial  angioma  or  cirsoid  aneu- 
rism. These  conditions  suggest  new 
growths  or  tumors  more  than  aneu- 
risms. Some  are  congenital ;  others 
are  acquired,  and  the  aneurism  by 
anastomosis,  a  vascular  tumor  consist- 
ing of  involved  arteries,  veins,  and 
capillaries,  which  may  reach  an  enor- 
mous size,  is  present.  The  arterial 
angioma  or  cirsoid  aneurism  usually 
occurs  upon  the  head  about  the  time 
of  adolescence.  It  may  be  congen- 
ital or  follow  traumatism.  The  ar- 
teries are  enormiously  dilated  and 
very  tortuous;  the  bruit  may  be  so 
loud  as  to  interfere  with  the  patient's 
sleep.  These  conditions  are  usually 
treated  by  electrolysis,  ligation,  or 
excision. 

W.  Wayne  Babcock, 

Philadelphia. 

ANGINA  LUDOVICI.       See 

Pharynx  and  Tonsils,  Diseases  of. 

ANGINA  PECTORIS.  —  DEFI- 
NITION. —  Angina  pectoris  (steno- 
cardia, breast-pang)  is  the  name 
given  to  a  group  of  symptoms  which 
usually  depends  upon  organic  disease 
of  the  heart  or  aorta.  An  attack 
consists  in  the  sudden  onset  of  agoniz- 
ing pain  in  the  precordial  or  sternal 
regions,  accompanied  by  a  feeling 
of  constriction  and  in  severe  cases  by 
a  sense  of  impending  death.  The  pain 
radiates  into  the  back,  the  shoulders, 
and  the  arms,  particularly  the  left.  The 
patient  is  pale,  haggard,  motionless,  and 
often  bathed  with  cold  perspiration. 

SYMPTOMS.— Suddenly,  after  ex- 
ertion, excitement,  or  a  hearty  meal, 


ANGINA   PECTORIS    (VICKERY). 


685 


the  patient  feels  an  excruciating, 
burning-,  or  tearing  pain  in  the  heart 
or  beneath  the  sternum,  accompanied 
with  a  sense  of  constriction  {angcre,  to 
throttle),  as  if  the  heart  were  in  a 
vise.  The  pain  radiates  into  the 
back,  upward  into  the  shoulders,  and 
down  the  left  arm,  often  even  to  the 
fingertips.  It  may  be  felt  in  both 
arms,  in  the  neck  and  head,  and  even 
in  the  trunk  and  lower  extremities. 
"In  true  angina  the  seat  of  the  pain 
may  be  entirely  away  from  the  chest, 
and  may  be,  as  in  Lord  Clarendon's 
father,  at  the  inner  aspect  of  the  arm, 
or  about  the  wrist,  or  in  rare  instances 
confined  tio  the  side  of  the  neck,  or 
even  to  one  testis"  (Osier).  After 
an  attack,  there  may  be  tenderness 
above  and  outside  the  left  nipple  and 
in  the  left  arm. 

The  pain  is  explained  by  James 
Mackenzie  as  a  sensory  reflex  due  to 
irritation  of  the  1st,  2d,  and  3d  dorsal 
and  8th  cervical  nerves,  and  the  sense 
of  constriction  to  reflex  stimulation 
of  the  intercostal  nerves. 

Paroxysms  occur  in  which  pain  is 
slight  or  absent  (angina  sine  dolor e). 
Early  attacks  are  often  of  this  sort 
Later  on  there  may  still  be  no  pain,  or 
the  paroxysms  may  sometimes  be 
painful  and  at  other  times  not. 

A  feeling  of  numbness  accompanies 
the  pain.  There  is  a  sense  of  impend- 
ing dissolution.  The  sufferer  sits  or 
stands  immobile  and  hardly  dares  to 
breathe.  Yet  there  is  no  real  dyspnea. 
The  face  is  pale  or  livid;  the  forehead 
wet  with  perspiration.  The  pulse 
may  remain  strong  and  regular. 
Usually  it  is  accelerated  and  of  in- 
creased tension.  A  pulse  of. habitual 
high  tension  may  be  somewhat 
lowered  during  the  attack  (Macken- 
zie).     The    pulse    may    intermit    or 


vary.  Exceptionally  it  is  slowed. 
The  paroxysm  lasts  a  few  seconds  or 
minutes, — sometimes  half  an  hour  or 
even  several  hours.  At  the  end  of  it 
the  patient  often  belches  gas  or 
vomits  or  has  a  movement  of  the 
bowels,  with  great  relief.  The  in- 
ference that  indigestion  has  caused 
the  paroxysm  is  natural,  but  probably 
erroneous;  although  it  is  true  that 
even  slight  exertion  directly  after  a 
meal  may  precipitate  an  attack. 

Study  of  21  cases.  The  attacks  usu- 
ally came  on  after  a  meal.  In  every 
case  exertion  increased  the  pain,  and 
the  sense  of  fullness  was  relieved  by 
the  eructation  of  gas.  Most  of  the  pa- 
tients attributed  their  trouble  to  indi- 
gestion. In  all  there  was  shallow  res- 
piration with  an  occasional  deep  inspi- 
ration. The  heart's  action  was  usually 
slow,  occasionally  palpitating  or  irregu- 
lar, and  the  pulse  was  generally  tense 
and  sustained.  In  all,  arterial  fibrosis 
could  be  recognized  by  a  thickening  of 
the  palpable  arteries ;  cardiac  disease 
manifested  by  accentuation  of  the  sec- 
ond aortic  tone,  feebleness  of  the  first 
sound,  cardiac  murmurs,  etc.,  was  pres- 
ent at  some  time  in  nearly  all  cases. 
During  the  attacks  the  second  aortic 
sound  was  always  much  accentuated, 
while  the  first  sound  could  be  heard 
very  indistinctly.  Frank  Billings  (Chi- 
cago Medical  Recorder,  Feb.   1901). 

Case  in  which  the  symptom-complex 
of  angina  pectoris  showed  none  of  the 
ordinary  causes,  namely,  syphilis,  alco- 
holism, nicotinism,  or  excessive  exer- 
tion. In  addition  to  excessive  mental 
toil  and  excitement  due  to  the  patient's 
occupation,  and  the  occurrence  of  rheu- 
matism nearly  half  a  century  before,  the 
only  factor  of  importance  was  the 
habitual  bolting  of  large  quantities  of 
food  rich  in  proteids  and  carbohydrates, 
producing  a  marked  disturbance  of 
metabolism,  as  evidenced  by  the  occur- 
rence of  indicanuria,  acetonuria,  and 
intercurrent  glycosuria  in  quantities  as 
great  as  8  per  cent.  Daland  (N.  Y. 
Med.  Jour.,  May  20,  1909). 


686 


ANGINA  PECTORIS    (VICKERY). 


The  attack  may  prove 'immediately 
fatal.  If  not,  the  patient  is  left  ex- 
hausted, but  regains  his  usual  condi- 
tion in  a  few  hours  or  days. 

The  attack  is  almost  sure  to  be  re- 
peated. This  may  happen  in  an  hour 
or  not  for  weeks  or  months.  The 
length  of  the  interval  depends  greatly 
upon  the  persistence  of  the  patient  in 
avoiding  the  exciting  causes.  After 
a  severe  attack,  rest  in  bed  is  desir- 
able for  several  days,  or,  if  the  patient 
is  much  enfeebled,  for  a  week  or  two. 
Successive  paroxysms  occur  with 
gradually  increasing  readiness. 

The  body  position  is  of  diagnostic 
value,  i.e.,  retroversion,  with  the  head 
and  trunk  extended,  the  whole  body 
being  fixed  in  this  attitude.  Not 
every  case  assumes  this  position,  bat 
it  is  sufficiently  constant  to  be  an  aid 
in  the  differential  diagnosis  in  the 
various  types  of  spasmodic  dyspnea — 
for  example,  in  asthma  or  uremia;  so 
that  in  addition  to  the  two  cardinal 
symptoms  of  pain  and  anguish  he 
would  add  a  hyperextended  position 
of  the  head  and  trunk.  This  attitude 
was  exemplified  in  the  six  personal 
cases.  Minervini  (Riforma  medica, 
Nov.  18,  1905). 

The  diagnosis  of  angina  pectoris,  at 
least  in  its  milder  form,  cannot  be 
made  from  the  history  alone.  The 
other  forms  of  cardiac  pain,  of  toxic 
or  neurotic  origin,  the  latter  especially 
in  women,  may  exactly  simulate  a  true 
angina  pectoris.  After  allowing  due 
weight  to  the  age,  sex,  and  detailed  his- 
tory of  the  patient,  it  is  necessary  to 
ascertain  the  presence  or  absence  of 
signs  of  organic  disease  at  the  root  of 
the  aorta.  On  this  hangs  an  enormously 
important  decision.  When  plain  signs 
of  general  arterial  or  aortic  disease  co- 
exist with  a  history  of  precordial  pain 
there  need  be  no  hesitation  in  making 
a  positive  diagnosis  of  true  angina  pec- 
toris. But  it  is  otherwise  in  patients 
with  cardiac  pain  in  whom,  as  may 
happen,  the  accessible  arteries  are  soft, 


and  who  do  not  present  signs  of  gross 
aortic  or  pericardial  lesions. 

In  diagnosing  between  true  and  false, 
organic  or  functional,  there  is  one  phys- 
ical sign  which  the  writer  believes 
positive.  It  is  so  slight,  and  apparently 
so  insignificant,  that  one  almost  hesi- 
tates to  mention  it.  It  is  simply  a  slight 
clicking  sound,  of  a  harsh  or  rough 
quality,  accompanying,  or  following  at 
barely  perceptible  interval,  the  sound  of 
aortic  closure.  It  is  not  an  accentuation 
of  the  closure  sound  of  the  valve,  such 
as  the  loud,  clean,  "cork  and  bottle" 
aortic  second  sound,  which  is  significant 
of  high  arterial  tension.  G.  R.  Butler 
(Archives  of  Diagnosis,  Oct.,  1909). 

DIAGNOSIS.— In  true  angina  pec- 
toris skilled  observers  almost  invaria- 
bly find  evidence  of  organic  cardiac 
or  aortic  lesion.  In  a  supposed  case 
these  should  be  sought  most  care- 
full}^  Particularly  to  be  looked  for 
are  arteriosclerosis,  hypertrophy  or 
dilatation  of  the  left  ventricle,  aortic 
regurgitation,  and  feebleness  of  the 
muscular  power  of  the  heart. 

The  great  fact  in  this  disease  is  the 
existence  of  pain  around  which  the  at- 
tendant phenomena  are  grouped.  It 
usually  radiates  to  one  or  both  shoul- 
ders and  arms.  There  are  usually  re- 
peated paroxysms  induced  by  exertion 
or  by  digestive  conditions.  Other  sen- 
sations are  faintness,  weakness,  and 
breathlessness.  Objectively,  there  are 
pallor  or  cyanosis,  immobility  or  con- 
tortions, dry  or  moist  skin.  The  vas- 
cular tension  varies  within  wide  limits, 
and  there  may  be  an  increased  flow  of 
urine  and  saliva.  G.  A.  Gibson  (Prac- 
titioner, Sept.,  1906). 

When  angina  pectoris  is  well  charac- 
terized, it  can  be  differentiated  in  a  de- 
cisive way  from  the  false  variety  by  the 
angor  animi  and  the  strong  sense  of 
imminent  dissolution.  Many  additional 
symptoms  may  be  associated  during  the 
paroxysms,  but  are  not  necessarihr 
present,  and  only  serve  to  corroborate 
the  diagnosis  of  true  angina.  Among 
these    are :      Respiratory    disturbances. 


ANGINA  PECTORIS    (VICKERY). 


687 


including  asthma,  dyspeptic  symptoms; 
and  vasomotor  disturbances,  such  as 
pallor  of  the  face  (rarely  lividity), 
sweats,  and  coldness  of  the  surface. 
Anders  (Jour.  Amer.  Med.  Assoc,  Nov. 
3,  1906). 

Intercostal  neuralgia  causes  pain 
along  an  intercostal  nerve,  not  radiat- 
ing- as  in  angina  pectoris.  It  presents 
points  tender  to  pressure-  near  the 
vertebrae  and  sternum  and  in  the 
axilla.  It  is  not  associated  with  dis- 
ordered circulation.  It  is  more  com- 
mon in  women  than  in  men. 

Gastralgia  is  apt  to  occur  when  the 
stomach  is  empty.  The  pain  does  not 
stream  into  the  shoulder  and  arm. 
While  there  may  be  collapse  and  a 
sense  of  impending  death,  there  is  no 
evidence  of  heart  disease.  Like  in- 
tercostal neuralgia  it  is  likely  to  occur 
in  anemic  young  women,  rather  than 
in  middle-aged  men. 

On  the  other  hand,  the  pain  of  true 
angina  pectoris  may  be  felt  lower 
down  than  the  precordia.  And,  as 
already  stated,  the  termination  of  an 
attack  may  be  marked  by  the  dis- 
charge of  gas.  Particularly  if  there 
is  no  extreme  cardiac  pain,  this  may 
lead  the  patient,  and  in  some  instances 
has  led  his  physician  astray. 

Cardiac  asthma  is  dyspnea  due  to 
a  weak  heart  and  occurring  more  or 
less  paroxysmally.  Pain  is  not 
prominent.  The  picture  is  apt  to  in- 
clude pulmonary  edema,  enlarged 
liver,  and  dropsy,  and  it  could  hardly 
be  mistaken  for  angina  pectoris. 
Mitral  disease  is  not  apt  to  be  asso- 
ciated with  angina  pectoris,  and  relief 
from  attacks  is  often  experienced 
when  a  mitral  leak  develops  in  an 
aortic  case. 

The  recognition  of  cardiac  lesions 
observed  after  attacks  of  angina  pec- 
toris is  of  great  importance,  inasmuch 


as  it  leads  the  physician  in  charge  to 
insist  on  perfect  rest  for  the  patient 
for  days  or  even  weeks  after  a  severe 
attack,  and  thus  prevents,  in  some  in- 
stances, sudden  death.  The  cases  in 
which  the  attacks  are  followed  by  the 
appearance  of  clinical  signs  in  the 
heart  may  be  divided  into  three 
classes.  In  the  first  group  there  is  a 
rise  of  temperature  and  a  slight  en- 
largement of  the  cardiac  area  of  dull- 
ness. The  fever  may  be  slight,  but 
if  other  causes  are  excluded  it  is  of 
great  value  in  the  diagnosis  of  myo- 
carditis following  angina  pectoris.  In 
the  second  group  there  is,  in  addition 
to  fever,  a  distinct  dilatation  of  one  or 
other  of  the  cardiac  cavities,  which  can 
readily  be  discerned  on  physical  exami- 
nation. Finally,  in  the  third  group, 
there  develops  an  acute  endocarditis 
following  an  attack.  In  spite  of  the  fact 
that  clinically  the  occurrence  of  acute 
endocarditis  after  angina  pectoris  is  not 
a  well-recognized  phenomenon  as  yet, 
it  has  long  since  been  described  patho- 
logically. Kernig  (Roussky  Vratch, 
Oct.  .30,  1904). 

"Pseudoangin  a." — Pseudoangina 
pectoris,  or  hysterical  angina,  occurs 
in  females  or  neurasthenic  men, 
usually  under  the  age  of  40,  without 
evidence  of  organic  cardiovascular 
changes.  There  are  low  tension, 
feeble  second  sound,  and  soft  arteries. 
The  attacks  are  spontaneous  and  are 
apt  to  be  nocturnal  and  periodic 
(menstrual).  They  last  an  hour  or 
two,  being  more  prolonged  than  the 
true  paroxysms.  The  patient  is  agi- 
tated, writhes,  or  walks  about  the 
room,  and  talks.  The  heart  feels  not 
constricted,  but  distended.  The  pain 
is  not  apt  to  be  so  severe  as  in  true 
angina  pectoris.  Paresthesise  and 
vasomotor  symptoms  are  prominent. 
The  patient's  symptoms  are  some- 
times colored  by  his  having  consulted 
encyclopedias  and  the  like  (Broad- 
bent).     Death  never  occurs. 


688 


ANGINA  PECTORIS    (VICKERY). 


Angina  pectoris  in  its  typical  form  is 
a  rare  disease.  Pseudoangina,  or  car- 
diac asthenia,  as  it  is  frequently  called, 
is  much  more  common.  It  is  erroneous 
to  speak  of  angina  pectoris  as  a  neuro- 
sis of  the  heart,  as  in  the  great  majority 
of  instances  there  are  organic  changes 
in  the  coronary  circulation,  the  cardiac 
muscle,  or  lesions  of  the  aortic  orifice. 
Neurotic  angina  is  exceptional,  is  al- 
most always  associated  with  spasm,  or 
with  a  sudden  increase  in  intracardiac 
pressure.  Beverly  Robinson  (Amer. 
Jour.  Med.  Sci.,  Feb.,  1902). 

Painless  angina  is  much  more  com- 
mon than  one  would  suppose  it  to  be 
from  the  infrequency  with  which  it  is 
mentioned;  but,  in  all  probability,  the 
disease  is  not  always  recognized,  and  the 
patient's  sufferings  are  attributed  to  hys- 
teria or  some  reflex  disturbance.  When 
the  symptoms  are  accompanied  by  a  di-' 
lated  right  heart  or  distinctly  athero- 
matous changes  the  diagnosis  is  easy, 
but  when  physical  signs  are  absent  it 
is  difficult  to  arrive  at  an  absolute  opin- 
ion. If,  when  free  from  the  paroxysms, 
the  patient  continually  suffers  from  a 
feeling  of  weight  or  distress  over  the 
precordia,  and  has  a  tendency  to  take 
occasional  deep  inspirations,  there  is  a 
strong  probability  that  the  right  ven- 
tricle is  affected,  and  this  amounts  to 
certainty  if  the  symptoms  are  invariably 
produced  or  aggravated  by  exertion. 
This  form  of  angina  is  entirely  different 
from  the  painful  variety,  and  in  many 
instances  demands  a  diametrically  oppo- 
site treatment.  W.  W.  Kerr  (Jour. 
Amer.  Med.  Assoc,  May  29,  1909). 

Hysteria. — It  should,  of  course,  be 
remembered  that  hysteria  may  be 
combined  with  organic  disease,  and 
that  a  careful  physical  examination 
should  be  made  in  any  suspected 
case;  but  the  discover}^  of  mitral  dis- 
ease would  not  be  inconsistent  with 
a  diagnosis  of  pseudoangina. 

There  is  a  nervous  form  of  syphilitic 
angina  which  is  distinct  from  hysterical 
angina  pectoris.  The  two  conditions 
may  be  distinguished  as  follows :  In 
hysterical  angina  the  attacks  come  on. 


as  a  rule,  at  night;  on  examination 
there  are  found  hysterical  areas  on 
the  skin  of  the  chest,  and  the  attacks 
begin  with  paresthesia  of  such  an 
area,  and  end  in  tears,  sobs,  and  other 
manifestations  of  excitement.  The 
syphilitic  attack  of  the  nervous  type 
is  preceded  by  fatigue,  not  by  ex- 
citement. It  is  very  important  to 
distingish  the  nervous  syphilitic  type 
from  the  organic  syphilitic  angina, 
which  depends  upon  a  lesion  of  the 
heart  muscle  itself.  The  chief  char- 
acteristic of  these  is  the  presence  of 
periodic  attacks  of  angina  with  dysp- 
nea between  the  attacks.  M.  J.  Breit- 
man  (Vratch,  Nov.  14,  1900). 

Hysterical  angina  pectoris  is  common, 
especially  before  the  age  of  40.  It  is 
most  frequent  in  women.  The  crises  in 
childhood  are  less  severe  than  those  of 
adult  life.  Almost  anything  may  be 
the  cause  of  the  attack,  even  acute 
articular  rheumatism.  Frequent  parox- 
ysms are  often  noted  about  the  meno- 
pause. Sometimes  an  attack  occurs  by 
suggestion  from  seeing  a  paroxysm  in 
another.  There  is  precordial  pain, 
often  with  a  distinct  aura.  The  parox- 
ysms occur  at  night,  periodically. 
About  the  precordia  is  generally  found 
an  area  of  marked  hyperesthesia.  Pal- 
pitation, rapid  pulse,  and  vasomotor 
symptoms  are  common.  In  fact  the 
symptomatology  is  polymorphous.  In 
some  cases  true  aortitis  or  endocarditis 
may  exist,  yet  the  attacks  of  angina 
pectoris  are  hysterical.  Mercklen 
(Medecine  moderne,  Apr.  23,  1902). 

Syphilis. — A  history  of  syphilis  in 
a  man,  even  if  under  40  years  of  age, 
renders  the  occurrence  of  true  angina 
pectoris  less  improbable  than  it  other- 
wise would  be,  for  there  is  a  possibility 
of  syphilitic  aortitis  obstructing  the  ori- 
fices of  the  coronaries. 

Tobacco,  Tea,  etc. — Excess  in  to- 
bacco (less  often  alcohol,  tea,  and 
coffee)  and  lead  poisoning  may  occasion 
spurious  angina,  or  again  they  may 
aggravate  a  genuine  paroxysm  depend- 
ing on  organic  lesions. 


ANGINA   PECTORIS    (VICKERY). 


689 


While  certain  cases  are  evidently  true 
angina  and  others  equally  obviously 
pseudoangina,  some  are  extremely  puz- 
zling. All  these  attacks  (true  and 
''false")  have  this  much  in  common, 
that  for  the  time  being  the  heart  is 
unable  to  perform  the  work  demanded 
of  it;  so  that  they  differ  more  in 
etiology  and  prognosis  than  in  imme- 
diate condition. 

ETIOLOGY.— ]\Iales  over  40  years 
of  age  in  comfortable  worldly  circum- 
stances make  up  the  majority  of  suffer- 
ers from  angina  pectoris.  Predisposing 
causes  are:  alcohol,  syphilis  (arterio- 
sclerosis, tabes  dorsalis),  rheumatism, 
gout,  diabetes,  chronic  nephritis,  and 
bacterial  infection  (influenza,  plague, 
malaria).  Sometimes  attacks  are 
hereditary. 

As  exciting  causes  may  be  named: 
physical  exertion,  mental  strain,  pro- 
found emotion,  and  digestive  disturb- 
ances. The  attacks  may  come  in  the 
daytime,  especially  at  first;  but  some 
of  the  worst  occur  at  night;  so  that 
finally  the  patient  may  dread  going  to 
sleep. 

Angina  pectoris  and  the  menopause. 
Attacks  of  angina  pectoris  observed 
for  the  first  time  at  the  menopause 
may  be  dependent  upon  the  changes  oc- 
curring at  this  period,  or  they  may  acci- 
dentally begin  at  this  time  from  other 
and  unassociated  causes.  In  the  former 
case  the  attacks  may  be  purely  neuras- 
thenic or  hysterical,  or  they  may  be  of 
vasomotor  origin  (spasm  of  the  coro- 
nary arteries),  giving  the  picture  of  se- 
vere organic  angina  pectoris.  These 
two  forms  may,  of  course,  be  combined. 
T.  K.  Geisler   (Vratch,  Feb.  12,   1900). 

All  cases  of  angina  pectoris  are  of 
toxic  origin,  and  the  so-called  coronary 
angina  is  a  toxic  neuralgia  or  neuritis  of 
the  cardiac  plexus,  due  to  uremia,  and 
to  be  forestalled  by  the  same  regimen 
as  uremia.  Gilbert  and  Garnier  (Presse 
medicale,  Oct.  13,  1900). 


The  writer  has  notes  of  268  cases  in 
all — 231  men,  Zl  women.  If  we  recog- 
nize a  mild  neurotic  or  pseudoneurotic 
and  a  grave  organic  or  true  form,  there 
wore,  of  the  former,  225,  and,  of  the  lat- 
ter, 43.  The  writer  omitted  \es  formes 
jrustes  unless  a  patient  had  subsequent 
severe  attacks.  Of  the  severer  form  of 
225  cases,  there  were  only  14  women. 
On  the  other  hand,  of  the  minor  type, 
of  43  cases  there  were  23  women.  The 
age  incidence  is  late,  the  largest  number 
of  cases  occurring  in  persons  over  50. 
Of  the  612  deaths  in  England  and 
Wales,  only  36  occurred  between  the 
ages  of  35  and  45,  while  between  45 
and  65  there  were  291  deaths.  In  Osier's 
list  the  age  was  much  t.ie  same.  There 
were,  under  30  years  of  age,  9;  between 
30  and  40,  41;  between  40  and  50,  59; 
between  50  and  60,  81 ;  between  60  and 
70,  62 ;  between  70  and  80,  13,  and,  above 
80,  3.  In  women  the  age  incidence  is, 
on  the  whole,  a  little  lower  than  in  men. 

A  point  that  stands  out  prominently 
in  the  writer's  experience  is  the  fre- 
quency of  angina  pectoris  in  physicians. 
Thirty-three  of  his  patients  were  physi- 
cians, a  larger  number  than  all  the  other 
professions  put  together.  Only  7  were 
above  60  years  of  age,  one  a  man  of  80, 
with  aortic  valve  disease.  The  only 
comparatively  young  man  in  the  list,  35, 
was  seen  nearly  twenty  years  ago  in  an 
attack  of  the  greatest  severity.  Worry 
and  tobacco  seem  to  have  been  the 
cause.  He  has  had  no  attack  now  for 
years.  Two  cases  were  in  the  fourth 
decade,  13  in  the  fifth,  and  11  in  the 
sixth.  Neither  alcohol  nor  syphilis  was 
a  factor  in  any  case ;  of  the  26  patients 
under  60,  18  had  pronounced  arterio- 
sclerosis and  5  had  valvular  disease.  In 
a  group  of  20  men,  every  one  of  whom 
Osier  knew  personally,  the  outstanding 
feature  was  the  incessant  trjeadmill  of 
practice,  and  yet  every  one  of  these  men 
had  an  added  factor,  worry. 

So  far  as  symptoms  are  concerned,  the 
writer's  cases  fall  into  three  groups : 
1,  les  formes  frustes;  2,  mild,  and,  3, 
severe. 

1.  The  mildest  form,  "les  formes 
frustes"  of  the  French,  with  substernal 
tension,      uneasiness,      distress,      rising 


1—44 


690 


ANGINA  PECTORIS    (VICKERY). 


gradually  to  positive  pain,  is  a  not  in- 
frequent complaint,  one,  indeed,  from 
which  few  escape,  is  associated  with 
three  conditions.  Emotion  is  the  most 
common  and  the  least  serious  cause. 

2.  Under  the  mild  form,  angina  minor, 
come  43  cases.  Osier  has  grouped  under 
these  the  neurotic,  vasomotor,  and  toxic 
forms,  the  varieties  which  we  formerly 
spoke  of  as  false,  or  pseudo-,  angina. 
The  special  features  of  this  variety  are : 
the  greater  frequency  in  women,  the 
milder  character  of  the  attacks,  and  the 
hopeful  outlook. 

3.  Severe  angina,  angina  major,  is  rep- 
resented by  225  cases,  of  which  211  were 
in  men.  Two  special  features  here  are, 
existence  in  a  large  proportion  of  all 
cases  of  organic  change  in  the  arteries 
and  liability  to  sudden  death.  Osier 
(Jour.  Amer.  Med.  Assoc,  from  Lancet, 
Mar.  12,  1910). 

PATHOLOGY.— It  is  exceptional 
for  attacks  of  true  angina  pectoris  to  be 
observed  in  persons  presenting  no  evi- 
dence of  organic  circulatory  lesion. 
The  commonest  underlying  conditions 
are  sclerosis  of  the  coronary  arteries, 
degeneration  of  the  myocardium,  car- 
diac hypertrophy,  atheroma  of  the 
aorta,  aneurism  of  that  vessel  near  its 
origin,  and  aortic  regurgitation.  There 
is,  however,  "hardly  an  affection  of  the 
walls  or  cavities  of  the  heart,  scarcely  a 
morbid  condition  of  the  arteries  that 
nourish  it  or  spring  from  it,  with  which 
the  distressing  malady  has  not  been 
observed  to  be  associated"  (Da  Costa). 

Recent  writers  lay  stress  on  oblitera- 
tion of  the  lumen  of  the  coronary  arter- 
ies as  the  essential  basis  of  true  angina 
pectoris,  which  obliteration  may  be  oc- 
casioned either  by  sclerosis  of  the  ves- 
sels or  by  changes  in  the  aorta  at  their 
origin.  "So  intimately  associated  is  the 
true  paroxysm  with  sclerotic  conditions 
of  the  coronary  arteries  that  it  is  ex- 
tremely rare  apart  from  them"  (Osier). 
Huchard  held  the  same  view. 


The  fact  that  angina  pectoris  occurs 
in  lesions  of  great  diversity  indicates 
that  some  condition  common  to  all  must 
be  the  cause  of  the  symptoms.  The  fact 
that  it  appears  only  after  the  heart- 
muscle  has  been  long  exposed  to  ex- 
cessive strain  points  to  the  cause  being 
situated  in  the  muscle.  All  the  func- 
tions of  the  muscle-fibers  save  that  of 
contractility  can  be  shown  to  be  intact 
in  many  cases  that  suffer  from  angina 
pectoris.  The  alternating  action  of  the 
heart  is  a  demonstrable  sign  of  ex- 
hausted contractility,  and  its  presence 
is  always  associated  with  symptoms  that 
are  included  in  the  symptom-complex 
of  angina  pectoris.  The  same  exciting 
cause- — extra  strain  on  the  heart — may 
provoke  both  the  angina  pectoris  and 
the  alternating  action,  and  both  may 
disappear  with  removal  of  the  cause. 
The  inference  to  be  drawn  from  the 
consideration  of  these  facts  is  that  the 
sjmiptoms  that  are  included  in  the  term 
"angina  pectoris"  are  so  closely  asso- 
ciated with  an  impairment  of  the  func- 
tion of  contractility  of  the  muscle-fibers 
of  the  heart  that  in  all  probability  an- 
gina pectoris  will  be  found  to  be  an  evi- 
dence of  the  impairment  of  the  func- 
tion of  contractility.  James  Mackenzie 
(Brit.  Med.  Jour.,  Oct.  7,  1905). 

The  importance  of  arterial  reflex 
having  its  origin  in  the  abdomen  has 
not  been  fully  appreciated.  While  the 
active  processes  of  digestion  are  going 
on,  there  is  an  influx  of  blood  into  the 
splanchnic  area.  This  drainage  into  the 
abdominal  vessels  is  balanced  in  the 
general  circulation  by  a  systemic  arte- 
rial contraction,  evidently  a  reflex  phe- 
nomenon originating  in  the  splanchnic 
system,  passing  to  the  vasomotor  cen- 
ter in  the  medulla  and  then  transmitted 
to  the  systemic  arteries.  The  changes 
in  the  systemic  arteries  are  a  reduction 
in  size  and  an  apparent  thickening  of 
the  arterial  wall.  The  degree  of  these 
changes  depends  on  the  kind  of  meal 
which  has  been  taken.  In  the  big  eater 
and  the  wine-drinker  the  arterial  con- 
traction is  associated  with  a  rise  of 
blood-pressure  and  a  true  increase  of 
arterial  tension.  This  reflex  varies  in 
delicacy  in  different  persons.     It  exists 


ANGINA   PECTORIS    (ViCKERY). 


691 


in  all.  The  author  is  convinced  that 
there  is  a  relation  between  this  phe- 
nomenon and  angina  pectoris,  and  cites 
several  instances  in  support  of  his  con- 
tention. He  shows  that  this  hypersen- 
sitiveness  of  the  vasomotor  center,  even 
in  grave  angina  pectoris,  can  be  re- 
duced, controlled,  or  even  removed  by 
dietetic  measures,  with  the  result  that 
the  anginous  seizures  are  removed  or 
greatly  modified.  In  cases  where  the 
arterial  spasm  is  associated  with  great 
anatomic  change,  either  in  the  myocar- 
dium or  in  the  coronary  vessels,  abso- 
lute cure  can  hardly  be  looked  for,  but 
in  all  cases  the  symptoms  of  angina 
pectoris  may  be  much  ameliorated  by 
conducting  the  treatment  in  accordance 
with  what  they  indicate.  Owing  to  the 
varying  degree  of  intensity  of  the 
symptoms,  the  writer  suggests  that  in 
classifying  the  cases  the  simplest  dis- 
tinction might  be  found  in  the  terms 
angina  pectoris  major  and  angina  pec- 
toris minor,  the  former  being  confined 
to  those  cases  in  which  there  is  believed 
to  be  permanent  anatomic  change  in 
the  heart  or  its  vessels.  W.  Russell 
(Brit.  Med.  Jour.,  Feb.  10,  1906). 

The  pain  of  angina  depends  upon 
vascular  distention  in  the  mediastinum, 
which  is  the  result  of  a  more  or  less 
localized  vasodilatation  and  of  a  more 
or  less  generalized  peripheral  vasocon- 
striction. It  would  seem  that  the  an- 
gina is  not  due  to  the  organic  lesions 
any  more  than  is  asthma  due  to  em- 
physema, or  migraine  to  atheroma  of 
cranial  vessels.  The  connection  be- 
tween the  organic  lesions  and  angina 
should  then  be  ascribed  to  the  chronic 
peripheral  vasoconstriction,  which  con- 
stitutes the  earliest  stages  of  many 
forms  of  chronic  organic  disease  of  the 
heart  and  vessels. 

Preventive  treatment  resolves  itself 
into  the  prevention  of  exaggerated 
peripheral  vasoconstriction,  continuous 
or  recurrent.  Purin-free  diet,  cutting 
down  of  the  intake  of  carbohydrates, 
especially  the  saccharine  carbohydrates, 
and  the  fats,  is  advocated.  Francis 
Hare  (Med.  Rec;,  Oct.  20,  1906). 

Angina  results  from  an  alteration  in 
the  working  of  the  muscle-fibers  in  any 


part  of  the  cardiovascular  system, 
whereby  painful  afiferent  stimuli  are  ex- 
cited. Cold,  emotion,  toxic  agents  in- 
■  terfering  with  the  orderly  action  of  the 
peripheral  mechanism,  increase  the  ten- 
sion in  the  pump  walls  or  in  the  larger 
central  mains,  causing  strain,  and  a  type 
of  abnormal  contraction  enough  to  exr 
cite  in  the  involuntary  muscles  painful 
afferent  stimuli.  Mackenzie  suggests 
that  there  is  rapid  exhaustion  of  the 
function  of  contractibility,  which  is, 
after  all,  only  the  fatigue  on  which 
Allan  Burns  laid  stress.  In  a  disturb- 
ance of  this  Gaskellian  function  is  to  be 
sought  the  origin  of  the  pain,  whether 
in  heart  or  arteries.  In  stretching,  in 
disturbance  of  the  wall  tension  at  any 
point,  and  in  a  pain-producing  resist- 
ance to  this  by  the  muscle  elements  lie 
the  essence  of  the  phenomena.  In  a 
man  with  arteriosclerosis  and  high 
pressure,  and  all  the  more  likely  if  he 
has  a  local  lesion,  a  syphilitic  aortitis 
for  example,  disturbance,  at  any  point, 
of  the  tension  of  the  wall  permits  the 
stretching  of  its  tissues.  Spasm  or  nar- 
rowing of  a  coronary  artery,  or  even 
of  one  branch,  may  so  modify  the  action 
of  a  section  of  the  heart  that  it  works 
with  disturbed  tension,  and  there  are 
stretching  and  strain  sufficient  to  arouse 
painful  sensations.  Or  the  heart  may 
be  in  the  same  state  as  the  leg  muscles 
of  a  man  with  intermittent  claudication, 
working  smoothly  when  quiet,  but  in- 
stantly an  effort  is  made,  or  a  wave  of 
emotion  touches  the  peripheral  vessels, 
anything  which  heightens  the  pressure 
and  disturbs  the  normal  contraction 
brings  on  a  crisis  of  pain.  Osier 
(Lancet,  Mar.  26,  1910). 

The  immediate,  precipitating  condi- 
tions of  a  paroxysm  are  not  known,  but 
they  are  supposed  to  be  connected  with 
disturbances  of  the  vagus,  or,  perhaps, 
the  sympathetic  nerves.  Nothnagel  re- 
ported a  series  of  cases  under  the  title 
"angina  pectoris  vasomotoria"  which 
seemed  to  be  due  to  a  pure  neurosis. 
They  followed  exposure  to  cold,  and 
were  ushered  in  by  spasm  of  the  pe- 
ripheral   arterioles,    which   presumably 


692 


ANGINA  PECTORIS    (VICKERY). 


produced  the  cardiac  disturbance  be- 
cause of  the  increased  exertion  de- 
manded of  the  heart  in  order  to  propel 
the  blood  through  narrowed  channels. 

Broadbent  describes  angina  vaso- 
motoria as  a  comparatively  favorable 
class  of  cases  of  high  arterial  tension 
associated  with  general  arteriosclerosis 
and  a  hypertrophied  heart  capable  of 
powerful  contraction.  "The  circulation 
in  the  coronary  arteries  may  be  suffi- 
cient for  ordinary  needs,  but  when  the 
arterial  tension  is  further  raised  by 
exertion  or  increase  of  peripheral  re- 
sistance attacks  of  angina  are  induced." 

From  a  neuralgia  or  a  neurosis  true 
angina  pectoris  differs  in  being  fre- 
quently fatal,  in  attacking  men  ten 
times  as  often  as  women,  and  in  being 
associated  with  organic  changes  in 
the  neighboring  structures,  viz. :  the 
heart  and  aorta. 

Lesions  of  the  cardiac  plexus  and  the 
branches  of  the  vagus  have  been  found 
in  repeated  instances  of  angina  pectoris, 
but  that  such  lesions  are  invariably  pres- 
ent and  essential  to  the  disorder  has  not 
yet  been  proved.  "The  cardiac  nerves 
may  be  seriously  implicated  in  aneur- 
ism, in  mediastinal  tumors,  in  adherent 
pericardium,  and  in  the  exudate  of 
acute  pericarditis,  without  causing  the 
slightest  pain"  (Osier). 

The  late  Sir  Benjamin  W.  Richard- 
son regarded  angina  pectoris  as  an 
actual  disease  analogous  (as  Trousseau 
held)  to  epilepsy,  and  due  to  a  disturb- 
ance in  the  sympathetic  nervous  system. 

Angina  pectoris  is,  in  the  main,  an 
angiospastic  disease,  and  it  may  easily 
be  understood  how  a  spasm  of  the  ar- 
teries may  extend  through  the  circula- 
tory system.  In  the  case  reported,  that 
of  a  man  aged  70  years,  the  symptoms 
of  angiospasm  in  the  extremities,  such 
as  cyanosis  and  pain,  were  replaced  by 
a   true    gangrene    of    the    upper   limbs. 


The  patient  had  suffered  from  anginal 
attacks  for  two  years,  during  which  he 
had  suffered  pain  and  numbness  in  his 
right  arm  and  hand.  The  gangrenous 
process  appeared  very  rapidly  and  con- 
tinued for  three  months,  after  which 
it  healed  completely,  not  leaving  any 
traces  whatever.  It  was  noted  that  dur- 
ing the  days  which  followed  an  attack 
of  angina  the  gangrenous  areas  looked 
worse,  and  the  secretion  had  a  more 
disagreeable  odor  and  was  more  abun- 
dant. E.  Salvini  (La  Riforma  Medica, 
March  23,  1907). 

Debove  says  that  in  tabetic  angina 
pectoris  there  is  no  organic  lesion  of  the 
heart  or  large  vessels,  and  that  the  at- 
tack must  be  regarded  as  a  visceral 
crisis.  Dana  refers  cardiac  crises  in 
tabes  to  a  degenerative  irritation  of  the 
vagus.  It  should,  however,  be  remem- 
bered that  aortic  disease  is  rather  fre- 
quent in  tabetic  patients. 

In  regard  to  the  causation  of  attacks 
of  angina  pectoris  in  the  graver  cases 
which  are  associated  with  serious  struc- 
tural disease  of  the  heart  and  vessels,  J. 
Burney  Yeo  states  that  in  by  far  the 
greater  number  of  deaths  from  organic 
disease  of  the  heart  all  the  various 
lesions  may  be  present  which  have  been 
found  in  fatal  cases  of  angina  and  yet 
no  true  anginal  attacks  have  ever  been 
complained  of.  In  his  opinion  there  is 
some  additional  circumstance  needed 
to  account  for  the  angina.  The  most 
serious  forms  of  angina  seem  to  have 
a  complex  causation.  First,  there  must 
be  a  neurosal  element;  the  nerves  of 
the  cardiac  plexus  suffer  irritation,  and 
an  intense  cardiac  nerve-pain  is  excited ; 
this  acts  as  a  shock  to  the  motor  nerves 
of  the  heart,  and  thus  reacts  on  the 
heart-muscle,  which,  in  fatal  cases,  is 
already  on  the  verge  of  failure  from 
organic  causes;  and,  if  there  should  be 
excited  at  the  same  time  some  reflex 
arterial  spasm,  the  heart  will  have  to 


ANGINA  PECTORIS    (VICKERY). 


693 


encounter  an  increased  peripheral  re- 
sistance as  well.  In  such  cases  the 
rapidity  of  the  fatal  issue  is  no  argu- 
ment against  the  neuralgic  nature  of 
the  angina.  In  certain  conditions,  espe- 
cially in  habitual  high  arterial  tension, 
strain  is  apt  to  fall  (when  the  aortic 
valves  are  competent)  rather  on  the 
first  part  of  the  aorta  than  on  the  ven- 
tricular surface,  and  anginal  attacks 
are  more  prone  to  occur  in  these  cases, 
as-  this  part  of  the  aorta  is  in  such  close 
relation  with  the  nerves  of  the  cardiac 
plexus,  rather  than  in  those  cases  in 
which  the  strain  is  felt  on  the  interior 
of  the  cardiac  cavities. 

The  causation  of  the  less  grave  and 
more  remediable  forms  of  angina  is 
also,  in  many  instances,  complex.  A 
cardiovascular  system  feeble  and  poorly 
nourished  on  account  of  anemia  may 
be  submitted  to  undue  strain;  or 
there  may  be  some  intoxication — such 
as  that  of  tea,  tobacco,  alcohol,  gout, 
or  some  intestinal  toxin — irritating  the 
cardiac  and  vasomotor  nerves,  increas- 
ing peripheral  resistance,  and  so  ex- 
citing anginal  attacks,  which  may  alto- 
gether pass  away  and  be  completely 
recovered  from.  Vasomotor  spasm  as 
a  unique  cause  of  attacks  of  angina 
must  be  set  aside  as  inconsistent  with 
extended  clinical  experience. 

Cases  of  angina  pectoris,  both  of  the 
milder  and  graver  forms,  occur  without 
any  evidence  of  vasomotor  spasm  or  of 
heightened  arterial  tension;  and  the 
conditions  of  heightened  arterial  ten- 
sion, together  with  a  feeble  cardiac  mus- 
cle, very  commonly  coexist,  without 
any  tendency  whatever  to  the  develop- 
ment of  anginal  attacks.  The  argument 
in  favor  of  a  vasomotor  causation  has 
been  inferred  from  therapeutic  experi- 
ment and  the  relief  to  the  paroxysm 
which  has  attended  the  use  of  agents 


which  cause  arterial  relaxation.  But 
most,  if  not  all,  of  these  vasodilators 
are  also  anesthetics,  and,  as  Balfour  has 
pointed  out,  it  is  probably  to  their 
anodyne  action  on  the  sensory  cardiac 
nerves  that  they  owe  their  chief  effi- 
cacy ;  Grainger  Stewart  also  has  pointed  • 
out  that  nitrite  of  amyl  has  a  direct 
effect  on  nervous  structures,  and  that 
it  relieves  other  forms  of  neuralgia. 

Certain  fallacious  conceptions  of 
angina  pectoris  prevail.  Thus,  in 
true  cardiovascular  angina  pectoris, 
peripheral  arterial  sclerosis,  cardiac 
hypertrophy,  and  high  blood-pressure 
are  essential.  This  is  by  no  means 
always  the  fact.  Arterial  change  may 
be  widespread  and  the  coronaries 
sclerotic  without  hypertrophy  of  the 
heart  or  rise  in  blood-pressure.  The 
sclerotic  or  atheromatous  process  may 
be  quite  limited,  localized  to  the  begin- 
ning of  the  aorta,  and  only  encroaching 
a  little  on  the  coronaries,  while  the  pe- 
ripheral vessels  may  be  normal.  Espe- 
cially irr  syphilitic  cases  are  the  condi- 
tions liable  to  be  thus  localized.  In  some 
of  the  most  serious  cases  there  may  be 
no  abnormal  arterial  pressure,  indicat- 
ing, perhaps,  a  weakened  cardiac  muscle. 
The  finding  of  aneurism  or  lesion  of  the 
aortic  valves  does  not  exclude  angina, 
but  is  rather  in  its  favor.  The  attacks 
are  not  always  few  in  number,  and  fol- 
lowing exertion,  and  life  is  not  neces- 
sarily cut  ofif  within  a  few  months  after 
the  appearance  of  the  disease.  Patients 
may  live  a  number  of  years  with  com- 
paratively frequent  attacks.  While  com- 
paratively rare  in  women,  the  disease  is 
by  no  means  unknown,  and  serious  mis- 
takes may  be  made  in  diagnosis,  espe- 
cially in  nervous  and  hysterical  cases. 
The  cardiopath  is  often  a  neuropath 
also.  Pain  is  not  always  excessive.  It 
may  be  mild  or  even  lacking;  its  radia- 
tion is  variable.  Even  in  fatal  cases 
there  may  be  no  constant  pain.  Uncon- 
sciousness, though  unusual,  is  seen  at 
times,  and,  while  the  patient  usually  is 
afraid  to  move,  and  will  not  lie  down, 
there  are  exceptions  to  this  rule.  Eruc- 
tations or  vomiting  during  an  attack  do 


694 


ANGINA  PECTORIS    (VICKERY). 


not  prove  it  to  be  a  false  angina  and 
not  organic  or  cardiovascular.  While 
the  disease  is  very  grave,  there  is  no 
certainty  that  death  is  imminent.  The 
kidneys,  as  well  as  the  heart,  must  be 
investigated  as  regards  prognosis.  J.  B. 
Herrick  (Jour.  Amer.  Med.  Assoc,  Oct. 
22,  1910). 

PROGNOSIS.  —  The  underlying 
condition  is  apt  to  prove  fatal  event- 
ually, and  it  may  end  life  in  the  first 
paroxysm ;  but  a  careful  regimen  may 
prolong  existence  for  years,  and  Flint, 
Bendel,  and  Labolbary  have  each  re- 
ported cases  of  recovery. 

The  signs  of  danger  during  any  par- 
ticular attack  are  the  subjective  sense 
of  impending  death  and  the  feebleness 
and  irregularity  of  the  pulse.  The  gen- 
eral prognosis  is,  of  course,  influenced 
by  the  stage  which  the  organic  circula- 
tory changes  have  already  reached. 

The  pseudoattacks  are  apt  to  be 
repeated  oftener  than  are  the  genuine, 
but  the  prognosis  is  good,  both  as  to 
life  and  as  to  the  final  disappearance  of 
the  trouble. 

In  common  with  all  other  observers, 
the  writer  finds  that  angina  pectoris  is 
more  common  in  the  male  than  in  the 
female,  in  the  ratio  of  63  to  48.  The 
youngest  patient  in  his  series  of  cases 
was  29  years  old ;  the  oldest,  76.  The 
longest  duration  of  the  recurring  syn- 
drome was  seventeen  years  ;  the  shortest 
was  found  in  three  who  died  in  the  first 
attack. 

Consideration  of  the  various  forms  of 
angina  pectoris  shows  the  following :  In 
coronary  sclerosis  there  were  56  cases 
in  all,  i.e.,  29  cases  without  other  appre- 
ciable changes  in  the  heart  and  27  with 
other  changes.  Evidences  which  Forch- 
heimer  considers  as  pointing  to  coronary 
sclerosis  are  the  existence  of  angina 
pectoris  and  certain  changes  in  the  aorta 
or  the  aortic  valves. 

In  the  aorta  we  find  as  evidence  of 
sclerosis  some  dilatation.  Most  fre- 
quently a  soft  aortic  systolic  bruit  is 
detected,  which  sets  in  a  little  after  sys- 


tole, most  commonly  combined  with  an 
accentuation  of  the  second  aortic  sound, 
especially  characteristic  when  the  blood- 
pressure  is  low.  Over  the  aortic  area 
are  found  systolic  bruits,  differing  much 
in  character,  sometimes  soft,  sometimes 
harsh,  but,  as  a  rule,  unlike  those  of 
aortic  sclerosis  due  to  other  causes. 
Moreover,  the  second  aortic  sound  is 
accentuated,  which  Fofchheimer  says  is 
a  fairly  reliable  differential  sign  between 
arteriosclerotic  changes  in  the  valve  and 
in  the  ordinary  form  of  aortic  stenosis. 

In  1  case  of  syphilitic  endarteritis 
there  existed  angina  pectoris  of  a  very 
severe  type,  the  physical  evidence  of  a 
mitral  lesion  and  of  myocardiac  insuffi- 
ciency. In  27  cases  which  were  devel- 
oped on  other  diseases,  the  before- 
mentioned  signs  were  present.  The 
coexisting  diseases  were  chronic  myo- 
carditis in  12,  mitral  lesion  in  6,  aortic 
lesions  in  4,  obesity  of  the  heart  in  4, 
alcohol,  diabetes,  chronic  nephritis,  of 
each,  2;  syphilis  and  cirrhosis  of  the 
liver,  1.  Nearly  all  of  these  had  evi- 
dence of  arteriosclerosis. 

In  the  cases  of  angina  in  which  coro- 
nary sclerosis  alone  existed  we  find 
3  dead  in  the  first  attack  and  7  others 
dead.  Of  the  latter,  2  died  of  diabetic 
complications,  1  of  complicating  pneu- 
monia in  the  status  anginosus,  death 
being  due  to  acute  cardiac  dilatation, 
1  of  a  cerebral  and  another  of  a  gastric 
hemorrhage.  So  that,  in  all,  in  only  6 
cases  could  death  be  attributed  to  the 
coronary  sclerosis.  The  duration  of 
the  disease  in  these  cases  varied  from 
sixteen  months  to  seventeen  years,  and 
all  were  males.  In  the  29  cases  of 
coronary  sclerosis  there  is  but  1  female. 

When  the  obstruction  is  due  to  throm- 
bosis or  embolism,  the  attack  is  usually 
fatal,  either  immediately  or  later  on,  as 
the  result  of  changes  in  the  myocar- 
dium. The  attack  is  always  immediately - 
fatal  when  one  coronary  artery  is 
closed.  As  a  rule,  death  occurs  in- 
stantaneously where  the  descending  or 
circumflex  branches  are  completely 
closed,  but  occasionally  the  patient  sur- 
vives for  a  few  days,  as  is  shown  by 
myocardial  infarcts  found  post  mortem. 
Forchheimer's  experience  leads  him  to 


ANGINA   PECTORIS    (VICKERY). 


695 


believe  that  when  both  cardiac  asthma 
and  angina  pectoris  arc  present  from  the 
onset  the  outlook  for  improvement  is 
very  small.  Rut  he  does  not  agree  with 
Neubiirger,  who  states  that  in  coronary 
sclerosis  there  are  3  stages  of  myocar- 
dial changes,  which  develop  and  which 
are  always  fatal. 

So  far  as  the  duration  of  the  disease 
is  concerned,  aside  from  those  who  died 
in  the  first  attack,  in  8  the  disease  lasted 
from  one  to  two  years ;  in  4  from  two 
to   four  years,   and   in    1    for   seventeen 
years.     Of  those  alive,  4  have  had  the 
disease    from    eight    to    ten    years,    the 
same  number  from  five  to  eight  years, 
and    iO    from    four   to    five    years.     F. 
Forchheimer  (Jour.  Amer.  Med.  Assoc, 
from  111.  Med.  Jour.,  May,  1910). 
TREATMENT.— During   a    parox- 
ysm the   first   remedies   to  employ  are 
such  as  will  dilate  the  arterioles.    Ni- 
trite  of  amyl   is  the  best  because  it 
acts    with    the    greatest    rapidity.     A 
"pearl"  of  this  drug  may  be  crushed 
in  a  handkerchief  or  in  cotton  placed 
in  the  bottom  of  a  glass  tumbler,  and 
inhaled.     Nitroglycerin    may    be    in- 
jected   subcutaneously     (M-OO     to    %o 
grain),  or  a  tablet  of  this  substance 
may   be    masticated,    or   a    minim    of 
spiritus    glycerylis    nitratis    may    be 
placed  upon  the  tongue.     It  is  readily 
absorbed    from    the    mouth    and    acts 
almost     as     quickly     as     when     given 
hypodermically.   Erythrol  tetranitrate 
has    an    action    like    nitroglycerin,    but 
milder  and  decidedly  more  prolonged. 
It  may  be  given  in  tablets  of  ^  to  2 
grains. 

Aiigina  pectoris  is  due  exclusively  to 
a  pain  in  the  diseased  aorta,  and  is  al- 
ways accompanied  by  a  peculiar  anguish. 
The  lesions  causing  the  pain  are  in  the 
first  part  of  the  ascending  aorta.  The 
attack  of  pain  is  brought  on  by  an 
emotion  or  an  effort,  and  these  causes 
are  precisely  those  which  increase  the 
blood-pressure.  The  diseased  aorta  is 
not  pamful  under  ordinary  conditions, 
but  the  pain  develops  as  the  blood-pres- 


sure rises,  and  it  is  favorably  influenced 
by  any  measure  that  reduces  arterial 
tension.  Josue  (Arch,  des  Mai.  du 
Cceur,  Oct.  1,  1908). 

Erythrol  tetranitrate  has  a  less 
marked,  but  more  lasting,  effect  than 
nitroglycerin.  It  is  especially  indicated 
in  those  patients  who  are  awakened  at 
night  by  the  pains.  Huchard  and  Fies- 
singer  (Jour,  des  praticiens,  Dec.  11, 
1909). 

The  treatment  of  an  actual  attack  of 
angina  pectoris  demands  three  consider- 
ations: (1)  Rest,  to  promote  restora- 
tion of  heart-power;  (2)  vasodilators, 
morphine,  to  relieve  the  pain  when 
this  is  not  achieved  by  rest  and  amyl 
nitrite  or  nitroglycerin.  In  cases  of 
severe  spasmodic  pain  in  middle-aged 
people,  amyl  nitrite,  by  lowering  ar- 
terial tension,  may  provide  instant 
relief;  but  in  those  cases  of  advanced 
fibroid  degeneration  in  old  people  in 
which  severe,  prolonged,  frequently 
occurring  attacks  of  cardiac  pain  ren- 
der life  a  burden,  the  only  drug 
which  seems  to  give  relief  is  mor- 
phine. .  F.  G.  Thomson  (Med.  Press 
and  Circular;  Jour.  Amer.  Med. 
Assoc,  Aug.  27,  1910). 

The  nitrites  are  sometimes  marvel- 
ously  efficacious  in  checking  an  attack, 
and  their  failure  to  give  benefit  does  not 
exclude  true  angina.  In  some  cases 
digitalis  does  more  good  than  all  the 
nitrites  or  iodides,  and  in  this  the 
writer's  experience  agrees  with  that 
of  Romberg,  who  advised  it  in  some 
cases.  J.  B.  Herrick  (Jour.  Amer. 
Med.  Assoc,  Oct.  22,  1910). 

Relief  by  these  means  is  often  im- 
mediate; but,  if  not,  ether  should  be 
inhaled.  Chloroform  is  also  advised 
by  excellent  authorities.  Flint  thinks 
it  not  without  danger,  if  the  heart  is 
weak ;  ether,  on  the  other  hand,  is 
a  stimulant.  Morphine,  subcutane- 
ously, is  a  valuable  and  sometimes 
an  indispensable  remedy.  Whittaker 
advised  that  it  be  given  with  cau- 
tion in  a  condition  which  may  any- 
way terminate  in  sudden  death.    The 


696 


ANGINA  PECTORIS    (VICKERY). 


morphine  (^  grain)  may  be  guarded 
by  atropine  {Yi^o  grain),  and  in  case 
of  alarm  also  by  strychnine  (%o  to 
%o  grain).  Electricity  has  also  been 
recommended. 

The  writer  has  never  witnessed  any 
fatality  from  morphine,  but  has  al- 
ways found  it  efficient  in  relieving 
the  pain  besides  combating  the  spasm. 
Nitrite  of  amyl  not  only  relieves  but 
keeps  the  patient  tranquil  when  he 
knows  that  he  has  it  always  with 
him.  Local  heat  is  also  useful  during 
an  attack,  and  applications  of  dry 
cups  in  the  axilla  or  on  the  back. 
When  there  is  much  dyspnea  inhala- 
tion of  oxygen  is  extremely  beneficial. 
Michaelis  (Therap.  der  Gegenwart, 
Dec,  1909). 

Factors  capable  of  bringing  on  the 
pain  should  be  carefully  avoided;  every 
renewal  of  it  keeps  up  ■  the  sum  of 
stimuli.  If  for  this  end  absolute  still- 
ness in  bed  be  required,  then  bed  it 
must  be,  with  the  corresponding  re- 
duction of  food.  If  at  first  the  at- 
tacks are  not  abolished,  they  will  be 
mitigated,  and  will  gradually  taper  off. 
All  measures,  medicinal,  dietetic,  etc., 
known  to  reduce  arterial  pressures 
should  be  enforced.  Sir  Lauder 
Brunton's  potent  means,  the  nitrites, 
are  indispensable.  To  guard  against 
vagus  inhibition,  atropine  must  be 
administered  regularly.  In  very  pain- 
ful cases  morphine  may  be  needed 
also.  An  ice-bag  applied  cautiously 
and  intermittently  to  the  upper  tho- 
racic spine  may  prove  helpful.  The 
cause  then  requires  treatment.  Of 
new  remedies  two  have  seemed  in  the 
author's  experience  to  be  efficacious, 
more  especially  in  angina  minor — 
namely,  (a)  the  high-frequency  cur- 
rent, and  (&)  the  administration  of 
the  lactic  acid  bacillus  by  the  method 
of  Metchnikoff.  Baths  and  massage 
cannot  be  prescribed  in  any  urgent 
stage  of  the  disease.  Causes  of  eccen- 
tric irritation  must  be  discovered  and 
neutralized.  The  patient  must  be 
warned  never  to  swallow  quickly,  nor 
to  bolt  large  morsels.  Diuretin  and 
aspirin  have  their  advocates.    Chloro- 


form is  very  dangerous  in  angina.  In 
syncopic  failure  of  the  heart  artificial 
respiration  should  be  tried.  AUbutt 
(Brit.  Med.  Jour.,  Oct.  16,  1909). 

Hot  and  stimulating  applications 
over  the  precordia,  such  as  a  strong 
mustard  poultice,  are  appropriate,  as 
are  also  heat  and  friction  for  the  ex- 
tremities. Sometimes  an  ice-bag  is 
put  over  the  heart.  By  some  it  is 
preferred  to  heat.  Alcohol  and  aro- 
matic spirit  of  ammonia  are  of  bene- 
fit in  case  the  cardiac  action  is  feeble. 
Syncope  demands  such  drugs  as  digi- 
talin,  caffeine,  strychnine,  and  cam-  ' 
phor,  employed  hypodermioally. 

Angina  pectoris  with  pseudosteno- 
cardia.  The. angina  is  due  to  probable 
endoaortitis,  and  is  relieved  by  an  ex- 
clusive milk  diet  and  theobromine  for 
two  weeks.  Then,  one  week  every 
month,  milk  diet  and  sodium  iodide. 
During  the  balance  of  the  month,  spe- 
cial diet,  with  the  theobromine  con- 
tinued. H.  Huchard  (Jour,  des  Prati- 
ciens,  Feb.  23,  1901). 

The  writer  has  employed  various 
forms  of  theobromine,  particularly 
diuretin,  in  a  number  of  cases  for 
several  years,  and  finds  it  efficient  in 
true  angina  pectoris.  It  is  well  borne 
in  doses  of  3  to  3.5  Gm.  per  day  (45 
to  52  grains).  Occasionally  it  pro- 
duces headache.  Breuer  (Miinch. 
med.  Woch.,  Phila.  Med.  Jour.,  Dec. 
6,   1902). 

Good  results  obtained  from  theo- 
bromine in  angina  pectoris.  In  1  case 
a  man  of  46  had  been  suffering  for 
two  months  from  repeated  attacks  of 
angina  pectoris,  recurring  so  con- 
stantly that  he  did  not  dare  to  go  to 
bed;  the  attacks  only  lasted  a  few 
minutes,  but  had  already  induced 
great  debility  and  distress.  Exam- 
ination revealed  insufficiency  of  the 
aortic  valve.  He  was  given  0.5  Gm. 
(7.5  grains)  of  theobromine,  and  the 
dose  was  repeated  at  bedtime.  There 
were  no  further  attacks  then  or  later. 
The  treatment  with  theobromine  must 
be    long    kept    up,    for    months    and 


ANGINA  PECTORIS    (VICKERY). 


697 


j^ears.  It  is  effectual  in  otiier  dis- 
turbances from  arteriosclerosis  as 
well.  Two  of  the  author's  patients 
recently  had  vertigo  and  were  afraid 
to  venture  into  the  street  on  foot,  but 
have  been  free  from  the  vertigo  since 
they  have  commenced  taking  theo- 
bromine. Marchiafava  (Policlinico, 
Feb.  28,  1909). 

Prolonged  rest  in  bed  advocated  in 
true  organic  cases.  Marked  improve- 
ment noted  in  most  of  the  20  cases 
studied.  The  patient  should  remain  in 
bed  at  least  two  weeks,  prolonged  to 
six  or  eight  weeks  in  cases  that  cannot 
walk  without  bringing  on  anginal  pain. 
Milk  diet  to  be  imppsed  from  the 
start;  later  farinaceous  foods  added. 
Drug  medication  by  theobromine, 
nitroglycerin,  and  even  morphine  and 
digitalin  also  utilized.  Greatest  im- 
provement in  old  patients  and  those 
losing  weight  during  treatment;  least, 
in  cases  with  associated  aortic  insuffi- 
ciency. Fiessinger  (Bull,  de  I'Acad. 
de  med.,  Nov.  29,  1910). 

The  present  writer  has  known  oxy- 
gen to  contribute  to  a  favorable  result 
in  collapse  due  to  chronic  myocarditis 
with  dilatation  of  the  left  ventricle, 
and  it  might  be  well  for  a  subject  of 
angina  pectoris  to  keep  some  ready 
in  his  house. 

The  painful  attacks  incident  to  car- 
diac disease,  such  as  angina  pectoris, 
also  paroxysms  of  tachycardia,  can  be 
mitigated  by  causing  the  patient  to 
belch  up  wind  from  the  stomach,  owing 
to  the  fact  that  the  heart  and  the  stom- 
ach are  both  innervated  by  the  pneumo- 
gastric  nerve.  Eructation  is  produced 
by  the  following  procedure :  The  pa- 
tient, seated,  takes  a  small  drink  of 
water  and  holds  it  in  his  mouth.  He 
then  throws  his  head  as  far  backward 
as  possible  and  swallows  the  water. 
The  posture  is  such  as  to  stretch  the 
esophagus  and  induce  in  the  pharynx  a 
sensation  which  causes  eructation,  pro- 
vided the  result  is  not  voluntarily  pre- 
vented by  the  patient.  It  is  well  to. 
warn  the  person  that  an  eructa;.ion  is 
desired;   otherwise,  he  may  restrain  it 


out  of  a  sense  of  decency.     Max  Herz 
Semaine  medicale,  June  3,  1908). 

Dyspeptic  disturbances  are  responsible 
for   or   at   least   aggravate   angina  pec- 
toris in  many  cases.     Great  benefit  can 
be  derived  from  magnesium  oxide  and 
peroxide  to  neutralize  abnormal  pro- 
duction of  gases  and  the  gastric  juice, 
and  promote  bowel  functioning.     Regu- 
lation of  the  diet  between  attacks  is  of 
supreme  importance.    Chlapowski  (Med. 
Klinik,  June  5,  1910). 
Between  attacks  it  is  of  vital  impor- 
tance to  avoid  the  predisposing  and 
exciting  causes.   Rest  and  moderation 
are  demanded,  especially  after  meals. 
As  for  drugs,  nitroglycerin,  taken  af- 
ter meals  in  doses  just  short  of  caus- 
ing headache,  has  a  distinct  inhibitory 
effect  upon  the  paroxysms.     In  some 
instances  it  might  be  better  to  order 
it  every  three  hours,  as  its  influence 
is    not    long    continued.      Nitrite    of 
sodium   (2  to  5  grains)   may  replace 
nitroglycerin. 

Laxatives  and  eliminative  treat- 
ment by  alkalies  are  often  of  great 
value. 

The  persistent  use  of  potassic  io- 
dide is  very  effective.  Ten  or  fifteen 
grains  may  be  given  thrice  daily 
before  meals  in  half  a  glassful  of  water ; , 
or  twenty  grains  three  times  a  day 
io'T  twenty  days,  followed  by  nitro- 
glycerin for  ten  days.  The  iodide  is 
believed  to  dilate  the  arterioles  and 
to  pro-mote  arterial  nutrition.  See 
supposed  that  also  by  enlarging  the 
caliber  of  the  coronary  arteries  it  in- 
vigorated the  myocardium. 

Arsenic  and  phosphorus  in  small 
doses  also  tend  to  avert  the  parox- 
ysms. In  case  of  fatty  degeneration 
of  the  heart  they  would  be  contra- 
indicated.  Barium  chloride  in  doses 
of  Yio  to  %  grain  after  meals  is  a 
good  tonic  for  cardiac  inefficiency, 
and  often  relieves  cardiac  pain. 


698 


ANHALONIUM    LEWINII. 


Quinine  and  methylene  blue  have 
also  been  recommended. 

The  treatment  by  saline  baths  and 
by  the  Schott  method  of  exercises 
has  a  most  potent  effect  in  improving 
the  condition  of  the  cardiac  muscle 
and  vessels,  and  appears  to  have  a 
direct  effect  in  making  the  attacks 
less  numerous  and  severe,  and  even 
in  causing  them  to  cease  during  a 
period  of  months  oi"  years.  The 
movements  must  be  made  with  es- 
pecial care  and  caution  in  these  cases, 
and  the  resistance  at  the  onset  must 
be  at  a  minimum.  The  artificial 
saline  baths  should  contain  from  1  to 
3  per  cent,  of  salt,  and  from  ^  to  1 
per  cent,  of  chloride  of  calcium,  and 
should  gradually  be  strengthened  by 
the  addition  of  carbonic  acid. 

Massage  three  times  a  week  and 
persisted  in  for  months  may  be  of 
great  benefit. 

In  most  cases  it  is  best  to  prohibit 
alcohol. 

The  cardiac  tonics — sparteine,  stro- 
phanthus,  strychnine,  valerian,  and  in 
suitable  cases  digitalis — are  of  the 
greatest  utility. 

The  general  tendency  to  anemia 
and  defective  oxygenation  must  never 
be  lost  sight  of,  and  general  tonics, 
including  the  use  of  oxygen  gas,  will 
be  of  excellent  service. 

Attacks  of  pseudoangina  may  be 
treated  with  asafetida,  ammoniated 
tincture  of  valerian,  or  compound 
spirit  of  ether,  and  the  outward  em- 
ployment of  heat,  friction,  and  rube- 
facients. Sometimes  recourse  must 
be  had,  however  reluctantly,  to  mor- 
phine. The  statement  in  clear  and 
decided  language  of  a  favorable  prog- 
nosis is  of  great  benefit.  Between  at- 
tacks the  underlying  condition  should 
be  carefully  sought  and  treated. 


Case  in  which  during  the  attacks 
the  pulse  rate  rose  to  120  and  the 
pressure  to  240,  varying  directly  with 
the  severity  of  the  pain.  Following 
the  administration  of  amyl  nitrite, 
the  pressure  sank  to  ISO,  coincident 
with  the  cessation  of  pain,  but  pres- 
sure rose  and  pain  returned  as  the 
efifects  of  the  drug  wore  ofif.  Mor- 
phine and  chloroform  produced  simi- 
lar efifects.  The  nervous  system  be- 
ing evidently  at  fault,  as  shown  by 
the  erethism  of  the  vasoconstrictor 
mechanism,  he  w^as  given  bromides 
with  good  effect.  This  case  presents 
the  typical  features  of  arterial  con- 
striction, more  marked  in  cases  of 
aortic  valvular  disease  than  in  other 
forms  of  angina.  In  all  forms  of 
angina  much  more  efficient  results 
can  be  obtained  by  attention  to  the 
nervous  system  than  by  cardiac 
therapy,  and  bromides  are  ideal  for 
such  a  purpose.  MacKenzie  (Heart, 
vol.  ii,  p.  265,  1911). 

Herman  F.  Vickery, 

Boston. 

ANGIOMATA.       See  Blood-ves- 
sels, TUMORS'OF. 

ANGIONEUROTIC  EDEMA. 

See  Ascites  and  Edema. 

ANHALONIUM     LEWINII 

(Mescal  Button). — The  mescal  button  is 
obtained  from  a  plant  growing  in  the  val- 
ley of  the  Rio  Grande,  in  Mexico.  The 
plant  is  of  the  family  Cactacese.  The  tops 
of  the  plant  when  dried  constitute  the 
commercial  Anhalonium  Lewinii,  first  in- 
troduced by  Lewin.  The  buttons  or  seeds 
are  brownish  in  color,  shaped  like  a  top, 
and  from  1  to  V/i  inches  in  diameter. 
They  are  hard  and  can  be  pulverized  in 
the  mortar  only  with  difficulty.  In  the 
mouth,  however,  under  the  action  of  the 
saliva,  they  swell  and  rapidly  become  soft, 
imparting  a  bitter,  nauseous  taste  and 
causing  a  marked  sensation  of  tingling 
in  the  fauces.  Four  alkaloids, — mescaline, 
anhalonine,  anhalonidine,  and  lophopho- 
rine, — closely  similar  in  their  physiological 
efifects,  have  been  extracted  from  this 
species  of  anhalonium.     From  the  related 


ANHALONIUM    LEWINII. 


699 


plant  Anhalonium  Williamsi  the  alkaloid 
pellotine  is  derived. 

PREPARATIONS    AND    DOSE.— The 

following  preparations  may  be  used: 
Tincture  (10  per  cent.)  ;  dose,  1  to  2  drams 
(4.0  to  8.0  C.C.).  Fluidextract  (100  per 
cent.);  dose,  lYi  to  IS  minims  (0.5  to  1.0 
c.c).  Powder;  dose,  TVj  to  15  grains  (0.5 
to  1.0  Gm.).  The  tincture  and  fluidextract 
should  be  made  according  to  the  processes 
prescribed  in  the  United  States  Pharma- 
copceia  for  "such  preparations. 

PHYSIOLOGICAL  ACTION.— Lewin 
found  anhalonium  to  be  an  intensely 
poisonous  drug.  A  few  drops  of  the  de- 
coction used  by  him  in  the  frog  sufficed  to 
produce  almost  instantly  changes  consist- 
ing chiefly  in  the  appearance  of  shrinking 
of  the  body,  so  that  the  batrachian  seemed 
to  pass  into  a  mummified  condition. 
Simultaneously  the  animal  raised  itself 
upon  its  extremities  and  remained  stand- 
ing in  this  position  like  an  ordinary  quad- 
ruped, or  crawled  about.  After  fifteen 
minutes  this  spastic  condition  passed  off 
and  the  frog  rapidly  returned  to  the  nor- 
mal state.  When  larger  amounts  were 
given  death  occurred  in  tetanic  rigidity. 
The  symptoms  produced  seemed  closely 
allied  to  those  of  strychnine,  Lewin  noting 
that  even  after  the  spinal  cord  was  severed 
peripheral  irritation  induced  tetanus.  In 
pigeons  it  was  found  that  the  drug  pro- 
duced convulsive  vomiting  in  a  few  mo- 
ments when  injected  hypodermically.  The 
bird  spread  its  wings,  crouched  down  to 
the  ground,  and  when  disturbed  exhibited 
muscular  twitchings.  Later  the  head  was 
drawn  sharply  back,  the  mouth  opened 
widely,  and  general  convulsions  appeared. 
When  death  occurred  the  heart  was  al- 
ways found  in  diastole.  In  rabbits  the 
symptoms  resembled  those  of  strychnine 
poisoning. 

In  the  human  subject  anhalonium  in 
large  doses  produces  an  effect  in  some 
ways  closely  resembling  that  of  Indian 
hemp:  visions  ranging  from  flashes  of 
color  to  beautiful  landscapes  and  figures, 
illusions  of  time  and  space,  etc.  This  and 
related  plants  are  employed  as  intoxicants 
by  certain  Mexican  Indians  in  connection 
with  religious  ceremonies.  According  to 
Prentiss  and  Morgan,  color  effects  consti- 
tute the  main  feature  of  the  drug's  action 


on  the  brain.  Consciousness  remains  un- 
impaired throughout  its  effects.  Mitchell 
states  that  sometimes  symptoms  resem- 
bling the  visual  phenomena  of  ophthalmic 
migraine  are  experienced.  The  after- 
effects were  also  found  by  him  to  be 
markedly  unpleasant,  nausea  and  headache 
appearing  which  lasted  for  S2veral  hours. 
Heffter  in  1898  carried  out  investigations 
on  himself  with  the  object  of  determining 
which  of  the  active  ingredients  of  mescal . 
produced  the  visual  hallucinations.  An 
alcoholic  extract  of  the  buttons  equivalent 
to  4^2  drams  was  taken,  and  afterward  a 
corresponding  amount  of  each  of  the  alka- 
loids. The  symptoms  produced  both  by 
the  alcoholic  extract  and  by  mescaline 
(1/^  grains)  were  colored  visual  hallu- 
cinations, slowing  of  the  pulse,  pupillary 
dilatations,  loss  of  time  relations,  heavi- 
ness of  the  limbs,  nausea,  and  headache. 
Anhalonine  and  anhalonidine  in  like 
amounts  induced  sleepiness  without  visual 
phenomena,  while  lophophorine  (%o  grain) 
caused  occipital  headache,  facial  redness 
and  burning,  and  a  temporary  slowing  of 
the  pulse.  Mescaline  was  thus  shown  to 
be  the  active-constituent  of  anhalonium  in 
respect  of  the  visual  phenomena. 

According  to  Dixon,  who  carried  out 
careful  pharmacologic  studies  of  anhalo- 
nium in  frogs,  cats,  and  rabbits  and  wit- 
nessed its  effects  in  man,  the  chief  effects 
of  the  drug  in  therapeutic  doses  appear 
to  be:  (1)  Direct  stimulation  of  the  in- 
tracardiac ganglia;  (2)  initial  slowing  of 
the  heart;  (3)  elevation  of  arterial  tension; 
(4)  direct  stimulation  of  the  brain  centers 
and  of  the  motor  spinal  centers,  as  shown 
by  an  increase  in  reflex  excitability. 

Full  doses  of  anhalonium  induce  motor 
weakness  and  inco-ordination.  In  still 
larger  doses  difficulty  of  respiration  ap- 
pears. Lethal  doses,  Dixon  found,  produce 
complete  paralysis,  and  death  is  caused  by 
respiratory  failure. 

THERAPEUTIC  USES.— Prentiss  and 
Morgan  employed  anhalonium  in  various 
conditions  dependent  upon  excessive  nerv- 
ous irritability,  with  considerable  success. 
While  not  a  hypnotic  in  itself,  the  drug  in 
therapeutic  doses  (7  to  15  grains)  often 
removed  the  cause  of  the  insomnia,  and 
thus  conduced  to  natural  sleep.  It  has 
been  credited  with  beneficial  effects,  espe- 


700 


ANIMAL   EXTRACTS    (SAJOUS). 


cially  in  neuralgic  headache,  acute  de- 
lirium, mania,  melancholia  and  hypochon- 
driasis, hysteria,  irritative  cough,  and  colic. 
Anhalonium  tincture  in  drop  doses  has 
been  claimed  to  be  useful  as  a  sustainer 
of  the  heart  action.  But  little  knowledge 
of  its  clinical  value  in  circulatory  disorders 
has  as  yet,  however,  been  obtained.  Ac- 
cording to  Landry,  the  drug  is  a  useful 
adjuvant  to  digitalis. 

The  taste  of  the  liquid  preparations  of 
anhalonium  is  bitter  and  unpleasant,  but 
can  readily  be  disguised.  Lewin  recom- 
mended for  this  purpose  the  use  of  fluid- 
extract  of  licorice  and  elixir  of  yerba 
santa  (fluidextractum  eriodictyi).  The 
powdered  crug  may  be  administered  in 
capsules  or  cachets. 

The  chief  untoward  action  to  be  feared 
in  the  event  of  excessive  dosage  of  this 
drug  is  respiratory  depression.  S. 

ANHIDROSIS.  See  Sweat 
Glands,  Diseases  of. 

ANIDROSIS.  See  Sweat 
Glands,  Diseases  of. 

ANIMAL  EXTRACTS,  OR 
ORGANOTHERAPY.— In  a  re- 
cently published  work  Parhon  and 
Goldstein,  of  Bucharest,  state  that 
"the  importance  of  the  internal  secre- 
tions in  physiology  and  pathology  can 
today  escape  no  one.  In  respect  to 
pathology  proper,  we  may  say  that 
there  is  no  branch  of  medicine  in 
which  the  problem  of  the  internal  secre- 
tions can  pass  unnoticed."  That  organ- 
otherapy has  also  earned  for  itself  an 
enviable  position  can  scarcely  be  de- 
nied, but  here  the  scientific  methods 
which  pathology  normally  imposes  have 
not  been  utilized  to  the  same  degree, 
and  empiricism  still  prevails  to  a  very 
large  extent.  Textbooks  of  therapeu- 
tics and  practice  still  adhere  to  the  con- 
venient statements  that  an  organic 
preparation  "is  useful,"  that  "it  is  rec- 
ommended," or  "has  proven  valuable" 
in  this  or  that  disease;  that  is  to  say, 


without  attempting  to  define  its  mode  of 
action.  The  cause  of  this  is  not  difficult 
to  find :  So  many  assumptions  as  to  the 
actual  functions  of  the  organs  used 
therapeutically  have  been  vouchsafed 
on  totally  inadequate  experimental  evi- 
dence that  textbook  authors  adopt 
none.  The  writer  of  the  present  arti- 
cle has  taken  another  course.  Reject- 
ing all  assumptions  based  on  inade- 
quate data,  he  has  collected  all  experi- 
mental and  clinical  facts  available, 
and  employed  these  as  the  stones  used 
in  the  elaboration  of  an  edifice  to  reach 
each  conclusion.  Time  has  sanctioned 
this  course.  The  conclusions  he  pub- 
lished in  his  "Internal  Secretions"  in 
1903,  vol.  i,  and  1907,  vol.  ii,  and  else- 
where, have  steadily  gained  adherents, 
supported  as  they  have  been  by  an  in- 
creasing number  of  confirmatory  facts 
contributed  independently  by  experi- 
menters and  clinicians.  He  feels  it  his 
duty,  therefore,  to  adopt  his  own  views 
as  the  foundation  of  the  following  sum- 
mary of  organotherapy,  knowing,  as  he 
does,  that  they  will  best  subserve  the 
interests  of  the  practitioner  arid  of  the 
sufferers  under  his  care. 

THYROID  GLAND  ORGANO- 
THERAPY.—In  the  latter  part  of 
the  last  century,  King,  of  London, 
showed  experimentally  that  the  colloid 
substance  of  the  thyroid  gland  passed 
directly  into  the  lymphatics.  Schiff,  of 
the  University  of  Geneva,  reviving 
views  in  1859  previously  held  by  many, 
found  that  this  organ  played  an  im- 
portant part  in  the  economy,  through 
some  substance  which  it  secreted,  and 
that  intraperitoneal  transplantation  of 
the  healthy  gland  in  a  dog  shortly  after 
thyroidectomy  had  been  performed 
prevented  the  cachexia  strumipriva 
and  violent  nervous  phenomena  which 
follow  this  operation.   Then  followed. 


ANIMAL   EXTRACTS    (SAJOUS). 


701 


in  1882,  the  lal)ors  of  the  l)n)tlicrs  Re- 
\crclin,  succeeded,  in  turn,  one  year 
later  by  those  of  Kocher,  of  Uerne, 
demonstrating  that,  in  man  as  well  as 
in  animals,  the  same  phenomena  oc- 
curred under  identical  circumstances. 

The  principal  postoperative  symp- 
toms noted  were  :  marked  weakness  and 
fatigue ;  a  sensation  of  cold,  pallor, 
hardness,  and  dryness;  edematous 
swelling,  thickening  of  the  skin,  and 
loss  of  hair,  all  with,  as  nervous  phe- 
nomena :  muscular  stiftness  and  pains ; 
tetany,  sometimes  attaining  the  violence 
of  true  tetanus,  and  even  clonic  convul- 
sions. The  brothers  Reverdin  termed 
this  condition  postoperative  myxedema, 
while  Kocher  called  it  cachexia  strumi- 
priva. 

The  thyroid  gland  per  se  was  subse- 
quently found  to  be  responsible  only 
for  the  myxedematous  symptoms,  how- 
ever. The  two  external  parathyroids, 
discovered  in  1880  by  a  Swedish  physi- 
cian, Sandstrom,  and  the  two  internal 
parathyroids,  discovered  by  a  French 
physician,  Nicolas,  of  Nancy,  in  1893, 
and  independently  by  Kohn,  of  Prague, 
in  1895,  were  subsequently  shown 
through  the  labors  of  Gley,  Vassale  and 
Generali,  Moussous,  Jeandelize,  and 
others  to  be  responsible  for  the  nervous 
phenomena,  tetany,  etc.  Briefly,  re- 
moval of  the  thyroid  alone  arrested  de- 
velopment and  caused  myxedema  (cre- 
tinism in  the  young),  while  removal  of 
the  parathyroids  alone  was  followed 
by  tetany  and  early  postoperative 
death. 

The  observation  of  Schiff,  con- 
firmed by  other  investigators,  that 
grafting  prevented  the  morbid  effects 
of  thyroidectomy  as  long  as  the  grafts 
lived,  led  Murray  and  Ord  to  try  the 
use  of  thyroid  extract  in  myxedema. 
Not  only  was  it   found  to  counteract 


this  disease  by  these  clinicians  and 
many  others  since,  but  thyroid  gland, 
which  includes  parathyroid ;  but  the 
latter  alone,  as  will  be  shown  under  a 
special  heading,  also  proved  valuable 
tlierapeutically  in  other  disorders. 

How  are  these  favorable  phenomena 
brought  about  ? 

PHYSIOLOGICAL  ACTION.— 
In  a  recently  published  work  on  thera- 
peutics (1911),  one  of  the  contributors 
states  that :  "the  manner  in  which  the 
thyroid  gland  presides  over  the  nutri- 
tion of  the  body  is  unknown.  It  is 
generally  admitted  that  it  furnishes  an 
internal  secretion,  that  this  secretion 
is  formed  by  the  living  cells  of  the 
vesicles,  and  that  it  is  poured  into  the 
colloid  material  they  contain.  But  our 
knowledge,"  remarks  the  author,  "has 
not  advanced  much  beyond  this  point." 
This  naturally  suggests  a  correspond- 
ing lack  o.f  knowledge  concerning  the 
physiological  action  of  thyroid  prepa- 
rations and  their  use  as  remedies.  But 
here,  as  elsewhere  in  the  realm'  of 
science,  the  world  has  not  stood  still. 

In  truth,  the  last  three  decades  have 
brought  out  facts  which  account  not 
only  for  the  nutritional  phenomena 
witnessed  under  the  influence  of  thy- 
roid preparations,  however  adminis- 
tered, but  also  for  autoprotective  or 
immunizing  functions  of  the  first  order. 

ACTION  ON  METABOLISM.— 
Some  physiologists  hold  that  the  thy- 
roid and  parathyroids,  by  means  of  an 
internal  secretion,  "exercise  an  im- 
portant control  over  the  processes  of 
nutrition  of  the  body,"  as  Howell 
states ;  others  contend  that  the  purpose 
of  these  organs  "is  to  neutralize  or  de- 
stroy toxic  substances  formed  in  the 
metabolism  of  the  rest  of  the  body." 
Others  again  assert  that  it  increases 
metabolic    activity,    especially    catabo- 


702 


ANIMAL   EXTRACTS    (SAJOUS). 


lism.  The  one  great  factor  which  stays 
all  progress  in  this  connection  is  the 
persistent  identification  of  these  func- 
tions as  separate  entities,  whereas  they 
are  in  reality  the  manifestations  of  a 
single  function.  That  such  is  the  case 
is  easily  demonstrable :  No  one  can 
deny  that  ''the  processes  of  nutrition 
of  the  body"  represent  a  phase -(that  of 
anabolism)  of  the  process  of  metabo- 
lism, nor  can  any  one  deny  that  catab- 
olismi,  the  other  phase  of  metabolism, 
serves  to  "neutralize  or  destroy  toxic 
substances"  formed  in  the  body  at 
large — and  to  break  down  fats,  as  is 
well  known.  If,  therefore,  the  thy- 
roid secretion  serves  to  activate  me- 
tabolism, as  first  shown  by  two  Italian 
scientists,  Vassale  and  Generali,  all  the 
other  processes  mentioned  are  also  in- 
fluenced by  the  thyroid.  That  such  is 
the  case  has  now  been  conclusively 
shown. 

[Chantemesse  and  Marie,  Ballet  and  En- 
riques  (cited  by  Popoff,  Arch  gen.  de  med., 
Oct.,  1899),  Bourneville  (Arch,  de  neurol., 
Sept.,  1896),  and  Shattuck  (Boston  Med.  and 
Surg.  Jour.,  June  30,  1904),  Lorand  (Lancet, 
Nov.  9,  1907),  and  many  other  cHnicians,  in- 
cluding myself,  have  noted  that  thyroid  prep- 
arations caused  a  rise  of  temperature  of 
several  degrees  and  that  it  took  part  in  the 
febrile  process.  These  observations  were 
controlled  by  those  of  Stiive  and  Thiele  and 
Nehring  (Zeit.  f.  khn.  Med.,  xxx,  p.  41, 
1896),  that  thyroid  extract  increases  over 
20  per  cent,  the  oxygen  intake  and  to  nearly 
as  great  a  degree  the  carbonic  acid  output. 
This  is  evidently  produced  by  the  active 
agent  of  the  thyroid  secretion,  iodine,  for 
this  halogen  itself  increases  oxidation  as 
well.  Thus,  Rabuteau,  Milanese,  and  Bou- 
chard (C.-r.  de  la  Soc.  de  Biol.,  pp.  227,  237, 
1873),  Henrijean,  and  Corin  (Arch,  de  phar- 
macodyn.,  ii,  1896)  have  all  noted  an  increase 
of  nitrogen  excretion.  Wood  ("Therapeu- 
tics," 13th  ed.,  p.  499,  1906)  and  Cushny 
("Pharmacology  and  Therapeutics,  4th  ed., 
p.  514,  1906)  state,  in  fact,  that  iodine  can 
produce  fever. 


Removal  of  the  thyroid,  on  the  other  hand, 
lowers  oxidation.  Albertoni  and  Tizzoni 
and  Magnus  Levy  (Zeit.  f.  khn.  Med.,  xxxiii, 
p.  269,  1897)  found,  for  example,  that  this 
procedure  decreased  markedly  the  output  of 
carbon  dioxide,  and  that  it  caused  hypo- 
thermia. The  fall  of  temperature  is  gradual, 
according  to  Lorrain-Smith  (Jour,  of 
Physiol.,  xvi,  p.  378,  1894),  and  most  marked, 
according  to  Rouxeau  (Arch,  de  physiol., 
xxix,  p.  136,  1897),  at  the  end  of  the  opera- 
tion. The  proportion  of  red  corpuscles  is 
reduced,  according  to  Moussu  (C.  r.  de  la 
Soc.  de  biol.,  p.  772,  1903).  Reverdin  ob- 
served in  man  that  the  hemoglobin  was  also 
diminished,  while  Horsley  noted  increased 
sensitiveness  to  cold.  Albertoni  and  Tizzoni 
and  Masoin  found  that  the  blood  contained 
less  oxygen  than  normally. 

This  applies  as  well  to  removal  of  the 
parathyroids,  which  was  found  by  Jeandelize 
("Insufficance  thyroidienne  et  parathyroid- 
ienne,"  p.  45,  1903)  also  to  lower  the  tem- 
perature. That  the  thyroid  apparatus  can 
itself  raise  the  temperature,  is  shown  by  the 
febrile  process  and  sense  of  heat  with 
flushing  observed  in  the  sthenic  stage  of  ex- 
ophthalmic goiter  and  when  the  thyroid 
apparatus  is  still  overactive.  When  thyroid 
extract  is  given  to  such  cases,  the  exchanges 
may  be  increased  to  a  surprising  degree — 77 
per  cent,  in  a  case  observed  by  Hirschlafif 
(Zeit.  f.  klin.  Med.,  xxxvi,  No.  3-4,  S.  200, 
1898-99).  The  disease  may,  in  fact,  be 
brought  on  by  thyroid  preparations,  as  noted 
by  Notthaft  (Centralbl.  f.  inn.  Med.,  April 
9,  1898)  and  other  clinicians.     C.  E.  de  M.  S.] 

The  process  through  which  general 
oxidation  and  metabolism  are  sustained 
by  the  thyroid  was  shown  by  myself,  in 
1903,  to  be  partly  due  to  excitation  of 
the  adrenals  by  the  thyroid  secretion 
contained  in  the  blood.  Starling  has 
since  (1906)  termed  "hormones"  sub- 
stances which  thus  act  as  stimuli  to 
other  organs,  while  Kraus  and  Fried- 
enthal,  Caro,  Hoskins,  and  others  have 
found  (1908-1910)  that  thyroid  ex- 
tracts excited  the  adrenals.  This  indi- 
rect action  I  also  found  in  1907  to  be 
supplemented  by  a  direct  action  on  the 
phosphorus  of  all  tissue-cells  (and  par- 


ANIMAL   EXTRACTS    (SAJOUS). 


703 


ticularly  of  their  nuclei),  the  iodine 
found  by  Uaumann  to  be  the  active 
agent,  in  organic  combination,  of  the 
thyroid  secretion  (as  well  as  of  the 
parathyroids,  as  shown  by  Gley),  ren- 
dering the  phosphorus  more  susceptible 
to  oxidation  by  the  hemoglobin. 

[Telford  Smith  (Lancet,  Oct.  7,  1897)  and 
other  clinicians  have  observed  that  the  use 
of  thyroid  preparations  in  young  cretins  was 
sometimes  attended  by  softening  of  the  bones 
and  bending  of  the  legs,  notwithstanding 
marked  general  improvement.  When  it  is 
recalled  that  five-sixths  of  the  inorganic 
matter  of  bone  consists  of  calcium  phosphate, 
it  becomes  a  question  whether  the  thyroid 
extract  does  not  interfere  with  the  building 
up  of  this  tissue.  That  such  is  the  case  is 
further  suggested  by  the  facts  that  iodine, 
the  active  constituent  of  the  thyroid  secre- 
tion, and  its  salts,  as  shown  by  Henrijean  and 
Corin  (loc.  cit.),  Handfield  Jones  (cited  by 
Wood,  loc.  cit.),  and  others,  cause  excessive 
elimination  of  phosphates  and  phosphoric 
acid,  and  that  thyroid  preparations,  according 
to  Roos,  Scholtz  (Central,  f.  inn.  Med.,  xvi, 
pp.  1041,  1069,  1895),  Pouchet  (Bull.  gen.  de 
therap.,  Sept.  15,  1905),  and  others,  act  in 
the  same  way.  "Emphasis  must  be  laid," 
writes  Chittenden  (Trans.  Congress  Amer. 
Phys.  and  Surgs.,  iv,  p.  93,  1897),  "upon  the 
apparent  connection  between  the  thyroid 
gland  and  phosphoric  acid  metabolism," 
giving  as  example  "the  increased  excretion 
of  P2O5  after  feeding  thyroids  to  normal 
animals,  and  the  great  decrease  in  the  case 
of  animals  with  the  thyroids  removed." 

The  untoward  effects  of  large  doses  of  thy- 
roid preparations  on  the  nervous  system, 
owing  to  its  wealth  in  phosphorus  and  fats 
as  manifested  by  tremor,  tachycardia,  optic 
neuritis  [Coppez  (Arch.  d'Ophtal.,  Dec, 
1900)],  etc.,  also  bespeaks  such  an  action; 
Cyon  (Arch,  de  physiol.,  x,  p.  618,  1898),  in 
fact,  found  that  injections  of  iodothyrin  ex- 
cited the  depressor  nerve  directly  to  such  a 
degree  that  the  vascular  pressure  often  de- 
clined to  two-thirds  of  the  normal. 

A  familiar  action  of  the  thyroid  prepara- 
tions is  a  rapid  reduction  of  fat  in  obese  sub- 
jects when  full  doses  are  administered.  The 
presence  in  the  fat-cell  of  a. nucleus  rich  in 
phosphorus    whose    purpose    is    promptly    to 


promote  oxidation  of  the  fat  when  the 
organism  requires  additional  carbohydrates 
explains  this  action.  Schondorff  (Arch.  f. 
d.  ges.  Physiol.,  Ixiii,  p.  423,  1896;  Ixxii,  p. 
395,  1897),  in  fact,  found  that  the  reserve 
fats  could  be  exhausted  before  the  nitrog- 
enous tissues  were  affected. 

The  mode  of  action  of  the  thyroid  active 
principle,  iodine,  is  suggested  by  the  presence 
of  this  halogen  in  all  nuclei,  as  shown  by 
Justus  (Virchow's  Archiv,  clxxvi,  S.  1,  1904) 
and  others.  This  means  that  iodine  is  found 
wherever  phosphorus  is  present,  while,  as 
shown  above,  it  is  most  active  where  phos- 
phorus is  known  to  be  most  plentiful.  Now, 
chemistry  furnishes  a  clue  to  the  manner  in 
which  all  the  phenomena  I  have  enumerated 
are  present:  "If  a  fragment  of  phosphorus 
lying  on  a  plate  is  sprinkled  with  iodine," 
writes  Wilson  ("Inorganic  Chemistry,"  p. 
284,  1897),  "the  substances  unite,  and  heat 
enough  is  produced  to  kindle  the  phos- 
phorus." Nitrogen,  hydrogen,  and  chlo- 
rine are  ubiquitous  constituents  of  our  tis- 
sues, and  the  vigorous  explosives  they  form 
with  phosphorus  and  the  intense  liberation 
of  heat  the  reactions  entail  are  familiar 
features  of  the  laboratory.  Roos  (Miinch. 
med.  Woch.,  No.  47,  p.  1157,  1896)  found 
that  in  a  dog  in  nitrogenous  equilibrium, 
iodothyrin  "caused  at  once  a  marked  increase 
in  the  output  of  sodium,  sodium  chloride, 
and  phosphoric  oxide"  (cited  by  Chittenden, 
loc.  cit.,  p.  89). 

Still,  as  Chittenden  states  (loc.  cit:,  p.  99), 
"according  to  Baumann,  doses  of  1  mg.  of 
iodothyrin  which  contain  only  0.1  mg.  of 
iodine  will  produce  a  decided  effect  upon  a 
goiter  after  three  or  four  applications, 
thus  clearly  indicating  that  it  is  not  the 
iodine  per  se  that  is  effective,  but  rather  the 
iodine  compound."  This  will  recall  the  ob- 
servations of  Notkin  and  vVhite  and  Davies, 
that  the  action  of  the  adrenal  secretion  re- 
sembles that  of  an  organized  ferment,  and 
my  own,  that  the  adrenal  principle  with 
which  the  iodine  is  combined  endows  it  with 
■  the  properties  of  a  ferment.  Hence,  the 
term  "thyroiodase"  I  have  applied  to  the 
thyroparathyroid  secretion.     C.  E.  de  M.  S.] 

When  in  the.  light  above,  we  admin- 
ister desiccated  thyroid,  which  com- 
bines the  actions  of  the  thyroid  and 
parathyroids,  corresponding  effects  are 


704 


ANIMAL   EXTRACTS    (SAJOUS). 


produced:  It  renders  the  phosphorus 
of  all  tissues,  and  all  free  substances, 
such  as  bacteria,  wastes,  toxins,  etc., 
containing  phosphorus,  more  inflam- 
mable or  sensitive  to  the  action  of  the 
oxygen  in  the  blood.  As  this  applies 
particularly  to  nerves  and  nerve-cen- 
ters (all  of  which  are  especially  rich  in 
phosphorus),  the  adrenal  center,  and, 
therefore,  the  adrenals  themselves,  are 
excited,  and,  the  adrenal  secretion  be- 
ing the  agent  which  takes  up  the  oxy- 
gen of  the  air  to  sustain  the  blood-oxy- 
genizing power,  the  supply  of  oxygen  is 
also  increased.  All  the  various  phos- 
phorus-laden substances  are  thus  not 
only  rendered  more  readily  oxidizable 
by  thyroid  extract,  but  this  remedy  also 
provides  indirectly  the  required  oxy- 
gen. Hence  also  the  familiar  in- 
fluence of  thyroid  preparations  on 
Dbesity,  their  action  being  mainly  ex- 
ercised upon  the  nucleus  rich  in  phos- 
phorus which  fat-cells  contain. 

The  wonderful  effects  of  thyroid  ex- 
tract in  cretinism  can  also  be  readily 
accounted  for:  The  rise  of  tempera- 
ture is  due  to  the  increased  oxidation 
brought  about  by  the  thyroid  and 
adrenal  oxidizing  substances  acting 
jointly;  the  enhanced  metabolism  is  a 
normal  result  of  the  augmentation  of 
general  oxidization,  while  the  increased 
appetite  is  due  to  the  resulting  greater 
^  demand  for  foodstuffs.  The  marked 
improvement  in  general  nutrition  and 
strength  is  a  self-evident  result  of  the 
assimilation  of  a  greater  proportion  of 
food  materials,  and  the  rapid  growth 
likewise.  The  cerebrospinal  system  is 
particularly  influenced  owing  to  its 
wealth  in  phosphorus ;  hence,  the  devel- 
opment of  intelligence.  All  organs  be- 
ing the  seat  of  active  metabolic  activity 
and  nutrition,  the  intestinal,  renal,  car- 
diac, and  cutaneous  and  hepatic  func- 


tions are  all  enhanced.  Even  the  hair 
grows  bountifully  not  only  in  cretin- 
ism, but  when  its  loss  is  due  to  general 
adynamia.  It  counteracts  premature 
senility  in  all  its  phases  by  restoring  to 
the  organism  the  one  constituent  which 
sustains  the  functional  efficiency  of  all 
its  parts. 

This,  it  must  be  emphasized,  is  the  ag- 
gregate of  effects  obtained  with  small 
doses,  at  most,  2  grains  of  the  desiccated 
thyroid  (which  represents  10  grains  of 
the  gland  proper),  three  times  a  day. 
When  larger  doses  are  given  another 
order  of  phenomena  is  awakened :  those 
of  excessive  burning  up,  as  it  were,  of 
the  tissues.  The  inflammability  of  all 
phosphorus-laden  elements  being  mark- 
edly enhanced  while  the  quantity  of 
oxidizing  substance  is  as  greatly  in- 
creased, the  tissue  elements  are  broken 
down  more  rapidly  than  they  are  built 
up,  beginning  with  the  fats,  and  the 
patient  becomes  emaciated. 

THE  THYROPARATHYROID 
SECRETION  AS  OPSONIN.— One 
of  the  functions  credited  to  the  thyroid 
gland,  we  have  seen,  is  "to  neutralize 
or  destroy  toxic  substances  formed  in 
the  metabolism  of  the  rest  of  the  body" 
(Howell).  This  is  justified  by  many 
established  facts.  Tetany,  as  shown  by 
the  brotdiers  Reverdin,  we  have  seen, 
follows  thyroidectomy;  it  is  now  rec- 
ognized that  this  is  due  to  a  general 
toxemia.  As  these  phenomena  were 
arrested  by  administering  thyroid  ex- 
tract, or  by  grafting,  as  long  as  the 
physiological  action  of  these  remedial 
agents  lasted,  it  became  evident  that 
the  thyroid  supplied  the  blood  with 
some  substance  which  in  some  way  de- 
stroyed the  spasmogenic  poison,  i.e., 
that  the  thyroid  product  was  an  anti- 
toxic substance.  This  is  further  sus- 
tained by  the  facts:   1,  that  the  blood 


ANIMAL   EXTRACTS    (SAJOUS). 


705 


of  thyroidectomized  animals  proved 
more  toxic  than  that  of  normal  ani- 
mals, and  that  it  caused  convulsions; 
2,  that  the  urine  of  thyroidectomized 
animals  ^vas  also  more  toxic  than  that 
of  normal  animals ;  3,  that  the  trans- 
fusion of  blood  of  the  latter  into  thyroi- 
dectomized animals  counteracted  for  a 
time  the  toxicity  of  both  their  blood  and 
urine.  These  and  other  facts  had 
shown  that  the  thyroid  gland — mainly 
owing  to  the  parathyroid  secretion  it 
contains — is  endowed  with  antitoxic, 
or,  as  they  have  been  sometimes  termed, 
"detoxicatory,"  functions. 

Yes;  it  is  evidently  not  only  "toxic 
substances  formed  in  the  metabolism 
of  the  body"  that  the  thyroparathjToid 
secretion  proves  antitoxic.  Charrin, 
Lindemann,  and  others  have  found,  for 
example,  that  animals  succumbed  more 
readily  to  infections  after  their  thyroid 
had  been  removed ;  Roger  and  Garnier, 
Kashiwamura,  and  others  found  that 
histologically  the  thyroid  showed  evi- 
dences of  marked  activity,  while  Torri 
noted  that  this  was  accompanied  by  an 
increased  production  of  their  colloid 
substance.  Hunt  has  shown  that  thy- 
roid feeding  renders  white  mice  much 
less  susceptible  to  poisoning  by  aceto- 
nitrile;  Vincent,  Frugoni  and  Grixoni, 
Leopold-Levi  and  Rothschild,  and  oth- 
ers have  observed  that  thyroid  prep- 
arations combated  effectively  various 
infectious  diseases,  including  erysipelas 
and  septicemia.  The  thyroparathy- 
roid  thus  showed  itself  antagonistic  to 
bacterial  toxins  and  certain  other  poi- 
sons, as  well  as  to  {oxic  waste  products. 

This  action  is  accounted  for  by  the 
fact,  pointed  out  by  myself  in  1903 
( "Internal  Secretions,"  vol.  i),  that  the 
thyroid  secretion  is  one  of  the  impor- 
tant agents  in  general  immunity — none 
of  the  active  factors  or  antibodies  of 


which  had  been  traced  to  their  source. 
I  found,  however,  that  this  action  was 
indirect,  i.e.,  that  the  thyroid  secretion 
or  extracts,  while  a  constituent  of  the 
blood's  antitoxin,  or  alexin,  increased 
the  immunizing  power  of  the  latter  by 
enhancing  the  functional  activity  of  the 
adrenals.  This  stimulating  influence 
on  the  adrenals  has  since  been  sus- 
tained by  the  investigations  of  Hoskins 
and  others  experimentally,  while  the 
participation  of  the  thyroid  in  the  im- 
munizing process  was,  four  years  later, 
confirmed  by  the  researches  of  L.  Fas- 
sin,  of  the  Bacteriological  Institute  of 
Liege. 

Experiments  to  ascertain  the  influence 
of  the  thyroid  gland  on  immunity.  The 
first  series  of  experiments  in  a  large 
number  of  animals  (dogs  and  rabbits) 
showed  that  the  subcutaneous  injection 
of  thyroid  product  (fluidextract  of  the 
fresh  gland,  the  thyroidin  of  Bur- 
roughs, .Wellcome  &  Co.)  is  rapidly  fol- 
lowed by  an  increase  of  alexin  in  the 
serum,  a  substance  discovered  by  Buch- 
ner,  generally  considered  as  playing  an 
important  role  in  the  defense  of  the 
body.  This  increase  becomes  evident 
as  early  as  ten  minutes  after  the  injec- 
tion; it  becomes  accentuated  after  one 
hour,  reaches  its  maximum  in  twenty- 
four  hours ;  then  the  proportion  of 
alexin  in  the  blood  recedes  more  or 
less  rapidly  until  the  normal  is  reached. 
The  effects  of  one  injection  rarely  last 
less  than  twenty-four  hours  or  more 
than  two  or  three  days.  The  writer 
also  found  that  the  oral  administration 
of  thyroid  brought  about  corresponding 
effects. 

To  control  these  results  as  to  their 
direct  relationship  with  the  thyroid,  the 
writer  performed  complete  thyroidec- 
tomy in  9  animals.  One  alone,  however, 
survived  the  operation  more  than  fifteen 
days,  tetany  occurring  in  all,  thus  show- 
ing that  the  parathyroids  had  been  com- 
pletely removed.  In  all  the  operated 
animals  there  occurred  a  marked  dimi- 
nution of  the  hemolytic  and  bactericidal 
alexin,    though     it    never     disappeared 


1—45 


706 


ANIMAL   EXTRACTS    (SAJOUS). 


altogether.  As  the  diminution  of  alex- 
in might  possibly  have  been  due  to 
traumatism,  the  operative  procedures 
were  repeated  in  fresh  animals,  leaving 
the  thyroid  in  situ.  But  neither  the 
traumatism  nor  even  removal  of  the 
spleen  caused  a  reduction  of  alexin. 
Louise  Fassin  (C.-r.  de  la  Soc.  de  Biol., 
vol.  Ixii,  pp.  388,  467,  647,  1907). 

Further  researches  on  the  nature  of 
the  process  through  which  the  thyroid 
secretion  enhanced  the  autoprotective 
power  of  the  blood  and  of  the  phago- 
cytic activity  of  the  migrating  and  sta- 
tionary (endothehal)  cells  brought  me 
in  1907  to  the  conclusion  that  the  thy- 
roid and  parathyroid  secretions,  acting 
jointly,  served  to  sensitize  all  phos- 
phorus-laden cells,  normal  and  patho- 
logical, and  that  this  thyroparathyroid 
secretion  and  Wright's  opsonin  were 
"one  and  the  same  substance."  Among 
the  more  direct  facts  which  sustained 
this  opinion  were  that,  while  substances 
capable,  as  are  the  opsonins,  of  sensi- 
tizing or  enhancing  the  phagocytic  ac- 
tivity of  leucocytes  had  been  found  in 
the  blood-plasma  by  Denys  and  Leclef, 
Bordet,  and  others,  and  Nolf  had 
shown  that  they  were  secreted  by  the 
red  corpuscles,  my  own  observations 
brought  out  (1)  that  the  composition 
of  these  sensitizing  substances  was 
similar  to  that  of  the  thyroparathyroid 
secretion,  i.e.,  that  they  contained  io- 
dine, nucleoproteid,  and  globulin,  and 
(2)  that  opsonins,  which  had  been  as- 
similated to  Bordet's  sensitizing  sub- 
stance by  Savtchenko  and  others,  were 
destroyed  at  the  same  temperature  as 
\  the  thyroparathyroid  secretion,  i.e.,  at 
60°  to  65°  C.  Briefly,  besides  being 
endowed  with  other  attributes  in  com- 
mon, the  sensitizing  substances  of 
Denys,  Bordet,  etc. ;  Wright's  opsonins, 
and  the  thyroparathyroid  secretion  all 
proved  to  be  plasmatic  products  of  the 


red  corpuscles,  and  to  show  similar 
chemical  properties.  Hence  my  con- 
clusion that  it  was  as  opsonin  that 
the  thyroparathyroid  secretion  pro- 
duced its  main  effects,  and  the  rec- 
ommendation that  thyroparathyroid 
preparations  be  used  in  various  in- 
fections, acute  and  chronic,  to  enhance 
the  opsonic  power  of  the  blood.  My 
position  has  been  sustained  by  several 
investigators. 

The  w^riter  reported  the  results  of 
experimental  and  clinical  observations 
which  had  led  him  to  conclude  that  the 
opsonins  of  the  tissue  juices  and  ex- 
udates were,  to  a  considerable  extent, 
the  product  of  the  thyroid  gland  while 
simultaneously  taking  part  in  the  main- 
tenance of  health  through  its  influence 
on  metabolism.  He  noted  elevation  of 
the  opsonic  index  of  the  serum  after 
injections  of  thyroid  extract  into  rab- 
bits. A  rabbit  treated  with  L5  c.c.  of 
the  extract  at  two  days'  interval  gave 
three  days  after  the  injection  an  opsonic 
index  =  2,  4,  for  example.  Another, 
given  the  preceding  day  1  c.c.  of  the 
extract,  gave  an  index  of  =  3.0.  These 
results,  obtained  in  many  animals,  and 
other  experiments  led  the  writer  also 
to  ascribe  the  opsonizing  action  of  thy- 
roid extract  to  the  thyroglobulin  of 
Oswald,  which  is  normally  present  in 
the  thyroid  gland.  Stepanoff  (C.-r.  de 
la  Soc.  de  Biol.,  vol.  Ixvi,  p.  296,  1909). 

The  writer,  having  also  advanced  the 
opinion  that  the  glands  with  internal 
secretion  probably  play  an  important 
role  in  the  phenomena  of  immunity, 
undertook  to  verify  this  view  experi- 
mentally, as  had  Stepanoff,  at  the 
Pasteur  Institute.  The  first  series  of 
experiments  aimed  to  ascertain  the 
influence  of  hyperthyroidization  on  op- 
sonic variations  in*  the  blood  of  guinea- 
pigs  and  rabbits,  using  mainly  the 
bacilli  of  tuberculosis,  diphtheria,  the 
Bacillus  coll,  and  the  staphylococcus  and 
streptococcus.  A  large  dose  of  thyroid 
(1  Gm.  per  kilo)  was  given  the  first 
day,  but  this  was  reduced  daily.  In 
this  series,  which  included  116  examina- 


ANIMAL  EXTRACTS    (SAJOUS). 


707 


tions,  tlic  writer  stales  tliat  lie  always 
observed  that  the  opsonic  power  of  the 
blood-scrum  increased  very  clearly  after 
thyroid  opotherapy.  It  was,  in  fact, 
considerably  more  than  doubled  in  all 
but  one  instance,  the  exception  being 
that  of  an  animal  in  which  an  emulsion 
of  Bacillus  coli  only  increased  the  op- 
sonic power  one-half. 

Might  the  ingestion  of  any  animal 
substance  by  herbivora  not  have  given 
rise  to  the  increase  of  opsonic  activity? 
Tlie  administration  of  corresponding 
quantities  of  horse  flesh  to  control 
failed  to  modify  the  latter  in  any  way. 
The  writer  found,  moreover,  that  the 
leucocytes  of  a  normal  animal  when 
treated  hi  vitro  with  the  serum  of  an 
hyperthyroided  animal  showed  a  dis- 
tinct  increase   of   phagocytic  activity. 

The  second  series  of  experiments  had 
for  its  purpose  to  ascertain  the  effects 
of  removal  of  the  thyroid  on  the  op- 
sonic properties  of  the  blood.  The 
serum  obtained  from  4  dogs  at  the  time 
of  the  characteristic  accidents  caused  by 
thyroidectomy  showed  in  every  instance 
a  most  evident  diminution  of  opsonic 
power.  The  same  experiments  con- 
ducted in  the  rabbit  gave  rise  to  the 
same  results,  i.e.,  he  always  found  a 
marked  decline  of  opsonic  power  in 
thyroidectomized  animals.  He  noted, 
moreover,  that,  while  traumatism,  even 
a  musculocutaneous  wound,  could  cause 
in  a  certain  measure  a  reduction  of 
opsonic  power,  the  latter  rapidly  re- 
turns to  normal,  while  it  maintains  itself 
a  very  long  time  at  the  same  level  in 
thyroidectomized  animals.  S.  Marbe 
(C.-r.  de  la  Soc.  de  Biol.,  vol.  Ixiv, 
p.  1058,  1908). 

On  the  whole  (referring  the  reader 
for  experimental  details  to  my  work  on 
the  internal  secretions),  the  physio- 
logical action  of  thyroid  preparations 
may  be  summarized  as  follows: — 

1.  They  enhance  oxidation  by  in- 
creasing the  inflammability  of. the  phos- 
phorus, which  all  cells,  particularly 
their  nuclei,  contain,  and  by  enhancing 
the  functional  activity  of  the  adrenals- 


2.  Their  power  to  enhance  the  in- 
ilammability  of  cellular  phosphorus  ex- 
tends to  pathogenic  elements,  bacteria, 
their  toxins  or  endotoxins,  toxic 
wastes,  etc.  As  such  they  act  as  opso- 
nins, and  render  these  pathogenic  ele- 
ments vulnerable  to  the  immunizinsf 
action  of  the  blood  and  its  phagocytes. 

THE  ACTIVE  PRINCIPLE  OF 
THYROID.— The  thyroid  product  is 
an  "iodized  globulin."  As  Notkin  and 
also  White  and  Davies  hold,  the  action 
of  the  thyroid  secretion  resembles  that 
of  an  organized  ferment.  This  finds 
its  explanation  in  the  fact  that  the 
thyroidin,  to  which  this  applies,  is 
mainly  a  ferment  plus  iodine.  The 
identity  of  this  ferment  suggests  itself 
when  we  consider  Baumann's  analyses 
of  his  thyroidin.  Among  other  tests, 
for  example,  he  found  that  it  was  prac- 
tically insoluble  in  ether  and  chloro- 
form; that  it  was  not  destroyed  by 
digestive  ferments,  and  that  it  stood  a 
temperature  of  100°  G.  These  are  the 
specific  tests  of  the  oxygen-laden  adre- 
nal product,  my  adrenoxidase.  Again, 
I  found  that  this  substance  gave  the 
tests  of  the  plasmatic  oxidase;  Lepin- 
ois  also  found  that  the  thyroid  secre- 
tion contained  an  oxidase  which  gave 
the  blue  reaction  with  tincture  of 
guaiac.  We  have  seen,  moreover,  that 
adrenoxidase  is  a  globulin :  Oswald 
termed  his  product  "thyroglobuHn"  and 
described  it  as  an  "iodized  glob- 
ulin." Several  other  facts  could  be 
adduced  to  show  that  this  constituent 
of  thyroidin  is  adrenoxidase.  This 
means  that  it  is  merely  the  albuminous 
portion  of  the  hemoglobin  which  enters 
the  thyroid  and  parathyroids  in  large 
quantities  with  their  rich  blood  supply. 
Another  constituent  of  thyroidin 
may  be  regarded  much  in  the  same 
light:  nucleoproteid.    Sherrington,  Mil- 


;08 


ANIMAL  EXTRACTS    (SAJOUS). 


roy  and  Malcolm,  and  others  have 
found  that  the  granulations  of  the 
most  numerous  leucocytes  in  the  blood, 
the  neutrophiles,  are  composed  of 
nucleoproteid,  while  the  observations 
of  Bail,  Stokes,  and  Wegefarth,  San- 
gree,  and  others  have  as  clearly  shown 
that  these  granulations  leave  the  pe- 
riphery of  the  cell.  Here,  again,  we  find 
in  the  secretion  a  supposed  intrinsic 
■component  which,  in  reality,  is  but  a 
commonplace  constituent  of  the  blood. 

This  harmonizes  with  the  familiar 
fact  that  in  the  absence  of  its  iodine 
the  thyroid  product  is  inactive.  It  in- 
dicates, moreover,  the  true  nature  of 
the  functions  of  the  thyroid  and  para- 
thyroids, to  collect  iodine  (brought  to 
them  by  certain  leucocytes,  as  I  have 
shown  elsewhere)  and  combine  it  orig- 
inally with  the  free  or  albuminous 
hemoglobin  and  nucleoproteid.  As  Os- 
wald holds,  therefore,  the  thyroid  prod- 
uct is  an  "iodized  globulin." 

PREPARATIONS  AND  DOSE. 
— The  implantation  of  a  portion  of  the 
thyroid  gland  beneath  the  skin  was 
soon  superseded  by  the  hypodermic 
method,  but  the  latter  presented  an- 
other drawback,  that  of  requiring  the 
constant  attendance  of  the  physician. 
Besides  this  the  preparations  often 
produced  suppuration.  The  gland  it- 
self, therefore,  administered  in  the  form 
of  desiccated  powder  in  tablets  or  cap- 
sules, is  preferred  by  the  majority  of 
practitioners.  This  presents  also  the 
advantage  of  conforming  to  the  U.  S. 
Pharmacopoeia    {thyroideum  sic  cum.) 

The  average-  dose  recommended  in 
the  former  Pharmacopoeia,  4  grains 
(0.250  Gm.),  which  suggests  from  3  to 
5  grains,  ivas  excessive,  each  grain  rep- 
resenting 5  grains  of  the  gland  proper. 
The  present  official  dose  is  1^  grams. 

For  reasons   submitted  in  the   fore- 


going pages,  small  doses,  from  ;^  to  2 
grains,  given  three  times  daily  in  the 
adult,  enhance  metabolism,  while  larger 
doses  so  stimulate  catabolism  that  they 
cause  undue  breaking  down  of  the  fats 
and  tissues. 

If  kept  up  too  long,  the  blood  ele- 
ments themselves  (hemolysis),  and 
even  the  tissues  (autolysis)  proper, 
may  be  destroyed.  Five-  or  even  4- 
grain  doses  are  never  indicated,  even  in 
the  treatment  of  obesity. 

By  loading  up  the  circulation  with 
toxic  wastes,  these  excessive  doses  may 
also  give  rise  to  tetanoid  movements 
and  even  to  true  tetany. 

An  important  feature  in  this  connec- 
tion, however,  is  that  the  unstandard- 
ized  preparations  of  desiccated  thyroid 
vary  in  strength  to  a  considerable  de- 
gree, and  that  a  small  dose  of  a  weak 
preparation  may  prove  practically  inert 
in  practice.  Dried  thyroids  are  now 
officially  required  to  contain  from  0.17 
to  0.23  per  cent,  of  combined  iodine. 
An  imported  desiccated  thyroid,  that  of 
Burroughs,  Wellcome  and  Co.,  is  also 
standardized,  each  grain  (representing 
about  6  grains  of  the  fresh  gland)  con- 
taining 0.05  grain  of  iodine  in  combina- 
tion. This  product  is  labelled  as  repre- 
senting a  given  amount  of  the  fresh 
gland.  It  is  available  in  small  tablets 
of  Yz,  1,  \y2,  2^,  and  5  grains. 

There  is  also  on  the  market  an  im- 
ported article  termed  iodothyrin,  a 
milk-sugar  triturate  of  the  thyroid 
active  principle,  1  Gm.  of  which  repre- 
sents 0.0003  Gm.  of  iodine.  The  dose 
for  adults  is  given  as  10  to  30  grs.  (0.6 
to  2  Gm.),  and  is  available  in  tablet 
form,  each  containing  5  grains  (0.33 
Gm.)  of  iodothyrin.  Its  manufactu- 
rers claim  that,  besides  possessing  the 
advantage  of  definite  strength,  it  is 
devoid  of  extraneous  matter.     It  is  not 


ANIMAL   EXTRACTS    (SAJOUS). 


709 


regarded  as  efficacious  as  the  desic- 
cated gland.  It  is  a  convenient  prep- 
aration for  young-  children,  however, 
owing  to  the  fact  that  it  occurs  as  a 
sweet,  whitish  powder. 

AMien  preparations  of  thyroid  gland 
— which  include  parathyroid — cannot 
be  obtained,  a  glycerin  extract  may  be 
prepared  by  divesting  a  sheep's  gland 
of  fat,  and  macerating  it  in  an  equal 
quantity  in  weight  of  glycerin  twenty- 
four  hours.  From  2  to  15  minims  of 
the  extract  may  be  given  daily  accord- 
ing to  age. 

The  writers  have  studied  in  goats  the 
therapeutic  effect  of  the  following  sub- 
stances :  thyroid  gland ;  iodothyrin ; 
thyroglobulin  ;  thyroproteid  ;  the  prod- 
ucts of  peptic  and  trj^ptic  digestion  of 
the  thyroid  gland,  including  primary 
and  secondary  albumoses  and  further 
cleavage  products,  obtained  separately. 
They  find  that  thyroid  gland  and  thyro- 
globulin have  a  marked  and  rapidly 
beneficial  action.  Secondary  albumoses 
derived  from  hydrolysis  of  the  thyroid 
are  also  active,  but  apparently  less  so 
than  the  former  substances.  Thyro- 
proteid, iodothyrin,  and  the  less  complex 
products  of  digestion  of  the  thyroid 
were  wholly  inert.  Their  experiments 
offer  no  ground  for  the  supposition  that 
iodothyrin  is  the  active  constituent  of 
the  gland,  or  even  that  it  is  one  of  the 
active  constituents.  Pick  and  Pineles 
(Zeitsch.  f.  exper.  Path.  u.  Therap.,  Bd. 
vii,  S.  518,  1909). 

UNTOWARD  EFFECTS  AND 
THEIR  PREVENTION.— The  dan- 
gers attending  the  use  of  thyroid  prep- 
arations depend,  to  a  degree,  upon  the 
manner  in  which  the  remedy  is  admin- 
istered. Beneficial  doses,  by  raising 
the  activity  of  all  metabolic  processes, 
prove  tonic,  increase  the  appetite,  the 
strength,  and  the  oxidations,  as  shown 
by  a  slight  rise  in  temperature.  When, 
however,  the  dose  is  too  large,  a  weak, 
rapid   pulse   and    shortness   of   breath, 


vomiting,  cardiac  oppression,  a  feeling 
of  tightness  around  the  chest,  vertigo, 
and  coma  may  supervene.  Excessive 
doses  have  also  caused  anorexia,  diar- 
rhea, malaise,  lassitude,  and  pain  in 
the  extremities ;  headache,  various 
eruptions,  urticaria,  transient  and  pap- 
ular erythema  and  eczema,  and,  in 
some  cases,  nervous  manifestations; 
neuralgia,  delirium,  convulsions,  delir- 
ium of  persecution,  aphasia,  monople- 
gia, etc.  When  dried  powder  or  com- 
pressed tablets  that  are  not  fresh  are 
used,  symptoms  of  ptomaine  poisoning 
may  be  added  to  those  mentioned. 
Hence,  the  observations  that  these  prep- 
arations are  more  likely  to  produce 
such  effects  during  the  warm  weather. 

The  best  guide  is  the  pulse.  Any 
considerable  quickening  or  palpitation 
should  lead  us  to  discontinue  the  drug 
until  the  cardiac  action  is  again  normal. 
There  areno  dangers  in  the  use  of  the 
drug,  provided  we  begin  with  small 
doses,  from  %  to  1  grain,  and  grad- 
ually increase,  watching  the  pulse.  It 
should  never  be  given  to  a  patient  who 
cannot  be  closely  watched. 

In  some  cases,  although  no  other  un- 
toward symptom  appears,  the  patient 
loses  flesh.  This  is  apt  to  occur  when 
2  grains  of  the  dried  gland  three  times 
daily  in  the  adult  is  exceeded. 

Chronic  poisoning,  characterized  by 
rapid  pulse,  emaciation,  weakness  of 
the  limbs,  general  debility,  and  mydria- 
sis have  also  been  observed  in  individ- 
uals who  had  undertaken,  without  med- 
ical advice,  to  treat  their  corpulency, 
and  who  had,  therefore,  subjected 
themselves  to  excessive  doses. 

TREATMENT  OF  THYROID 
POISONING.— As  a  rule,  cessation 
of  the  use  of  thyroid  preparations  ar- 
rests the  untoward  effects.  When  such 
is  not  the  case,  however,  arsenic,  as 


710 


ANIMAL   EXTRACTS    (SAJOUS). 


shown  by  Mabille,  antagonizes  the 
toxic  phenomena.  Fowler's  solution, 
from  314  to  5  drops  three  times  daily, 
suffices  in  most  instances  to  arrest  all 
morbid  effects. 

Mabille's  observation  that  arsenic 
obviates  the  unpleasant  symptom  ex- 
cited by  thyroid  preparations  con- 
firmed. In  S  cases  of  idiopathic 
goiter,  in  1  case  of  obesity,  and  1  of 
infantile  myxedema,  iodothyrin  was 
given  in  progressive  doses  of  from 
3%  to  30  or  3Sy2  grains  daily.  At  the 
same  time  arsenic  was  given,  either 
in  pills  or  as  Fowler's  solution,  in 
doses  increasing  proportionately  to 
the  iodothyrin  of  %4  to  Yio  or 
even  %  grain  daily. 

The  observations  of  the  writer  fully 
confirmed  Mabille's  experience,  for, 
though  the  7  cases  took  respectively 
231,  111,  86,  320,  108,  296,  and  125 
iodothyrin  tabloids,  containing  nearly 
4  grains  each,  beyond  occasional  in- 
creased frequency  of  the  pulse  no  symp- 
toms of  thyroidism  appeared,  so  that 
the  course  could  be  continued  unin- 
terruptedly. Arsenic,  therefore,  appears 
to  suppress  thyroidism  with  greater  cer- 
tainty than  atropine  does  iodism,  and  it 
is  now  possible  to  give  iodothyrin  safely 
in  doses  and  for  a  period  capable  of 
producing  definite  therapeutic  effects. 
Ewald  (Die  Therapie  der  Gegenwart, 
Sept.,  1899). 

The  writer  has  also  observed  that 
arsenic  exerts  a  specific  influence  upon 
the  activity  of  thyroid.  Patients  who 
took  an  arsenical  and  thyroid  prepara- 
tion synchronously  never  complained  of 
any  deleterious  effects,  while  those  who 
were  treated  with  thyroid  alone  occa- 
sionally exhibited  untoward  symptoms. 
So  pronounced  was  the  modifying 
power  of  arsenic  that  in  the  course  of 
time  he  never  prescribed  thyroid  prep- 
arations without  adding  arsenic  in  some 
form.  Heinrich  Stern  (Jour.  Amer. 
Med.  Assoc,  Feb.  15,  1902). 

The  addition  of  a  cardiac  tonic, 
preferably  adonidin,  to  thyroid  is 
recommended  whenever  the  latter  prep- 
aration is  to  be  used  for  any  length  of 


time.      The    following    formula    is    em- 
ployed : — 

B  Sodium  cacodylate    %oo  gf- 

Adonidin    %o  gr- 

Thyroid  gland  (dry 
powder)    1  gr. 

For  1  compressed  tablet.  When 
fresh  adonidin  cannot  be  obtained  (its 
price  is  exceedingly  high),  caffeine 
may  be  substituted  in  doses  of  Yq 
grain.  Thyroid  therapy  will  receive  a 
new  stimulus  as  soon  as  the  medical 
profession  appreciates  the  fact  that 
the  addition  to  the  thyroid  of  proper 
amounts  of  arsenic  and  a  cardiac 
remedy  will  render  the  medication 
more  efficient  and  deprive  it  of  all  or 
nearly  all  its  deleterious  effects. 
Heinrich  Stern  (American  Medicine, 
Jan.,  1910). 

THERAPEUTICS.— The  many 
disorders  in  which  thyroid  prepara- 
tions have  been  recommended  ("nearly 
all  the  chronic  and  many  of  the  acute 
troubles  known  to  humanity,"  as  one 
author  remarks)  have  naturally  in- 
spired considerable  mistrust  as  to  their 
actual  therapeutic  value.  Gradually, 
as  the  harmfulness  of  large  doses  as- 
serted itself  and  the  physiological  role 
of  the  thyroparathyroid  apparatus  be- 
came unraveled,  however,  their  indi- 
cations became  better  defined.  It  may 
now  be  said  that  in  sharp  contrast  with 
the  empirical  methods  of  the  past  thy- 
roid preparations,  when  employed  in- 
telligently, are  of  great  value  in  many 
disorders,  both  acute  and  chronic. 

As  far  as  the  author  can  elicit  from 
his  own  investigations  in  practice  as  to 
the  use  of  the  thyroid  gland  and  its 
preparations,  the  latter  has  a  far  wider 
sphere  and  use  than  may  be  realized 
by  the  average  practitioner.  He  has 
tried  its  use  and  derived  a  great  deal 
more  benefit  than  he  could  imagine  in 
such  conditions  as  myxedema,  obe- 
sity, cretinism,  exophthalmic  goiter, 
one  case  of  acromegaly,  and  various 
skin  affections.  Samuel  Robbinovitz 
(N.  Y.  Med.  Jour.,  Nov.  27,  1909), 


ANIMAL   EXTRACTS    (SAJOUS). 


711 


In  the  liglit  of  the  functions  attrih- 
uted  to  the  thyroid  secretion  in  the 
foregoing  pages,  it  governs  tissue  me- 
tabohsm  by  rendering  all  phosphorus- 
laden  cells  susceptible  to  oxidation. 
When,  therefore,  the  thyroid  principle 
is  deficient  in  the  body,  both  phases  of 
metabolism — including, of  course, that 
of  carbohydrates — the  building  up  and 
the  breaking  down  of  tissues,  are 
correspondingly  inhibited.  The  most 
exaggerated  expressions  of  this  condi- 
tion are,  as  is  well  known,  the  syn- 
dromes known  as  myxedema  and  cre- 
tinism. The  characteristic  symptoms 
of  these  disorders  exemplify  clearly 
deficient  metabolic!  activity  and  its 
consequences.  In  myxedema  we  have, 
among  other  symptoms,  for  example, 
the  low  temperature,  95.5°  F.  in  some 
instances,  both  in  the  mouth  and  rec- 
tum; great  sensitiveness  to  cold, 
reduction  of  the  urea  output — some- 
times to  50  per  cent,  of  the  normal — 
cyanosis  of  the  lips,  ears,  and  extrem- 
ities on  exposure  to  slight  cold„  and 
many  secondary  results  of  defi- 
cient metabolic  activity,  anemia  with 
marked  pallor,  general  relaxation 
of  the  arteries,  muscular  weakness, 
mental  torpor  and  vertigo,  and  the  cu- 
taneous anesthesia.  In  the  cretin,  we 
have,  besides,  all  the  phenomena  of  ar- 
rested development,  both  physical  and 
mental,  as  shown  by  the  dwarfed  body 
and  the  idiocy. 

Hypothyroidia,  or  Hypothyroid- 
ism.— This  is  a  condition  akin  to  the 
above,  but  much  less  marked,  fre- 
quently met  in  practice.  The  thyroid 
apparatus  supphes  a  part  only  of  that 
required  by  the  tissues,  and  the  result- 
ing phenomena  recall  closely  some  of 
those  observed  both  in  myxedema  and 
cretinism :  chilliness  and  subnormal 
temperature,  coldness  of  the  extrerni- 


ties  and  sensitiveness  to  cold ;  fatigue 
on  slight  exertion ;  constipation  with 
tendency  to  tenesmus ;  frequent  at- 
tacks of  migraine,  "sick  headaches" 
with  nausea,  vomiting,  etc.,  and  other 
periodic  manifestations  of  autointox- 
ication— due  to  inadequate  reduction 
of  waste  products  and  their  retention 
in  the  blood.  The  skin  taking  part  in 
the  process  of  elimination,  urticaria 
and  eczema  are  frequently  observed, 
while  transitory  edemas  of  the  brow, 
around  the  eyes,  and  sometimes  of  the 
face,  even  in  the  absence  of  albumi- 
nuria or  casts,  point  to  renal  fatigue. 
Enuresis  is  commonly  observed  in 
children  of  this  type  and  may  persist 
to  adult  age.  The  patient  is  subject  to 
frequent  catarrhal  disorders  of  the  re- 
spiratory passages,  usually  ascribed  to 
colds,  but  due  mainly  to  vascular  and 
glandular  relaxation.  A  tendency  to 
early  alopecia,  including  the  eyebrows 
(especially  the  outer  third),  is  also 
noticeable — a  sign  of  deficient  general 
nutrition  which  coincides  with  a 
marked  proclivity  to  early  senility. 

In  women  the  menstruation  appears 
late,  owing  to  retarded  development, 
and  there  is  a  proclivity  to  metrorrha- 
gia due  to  laxity  of  the  muscular  coats 
of  the  uterine  arterioles,  while  pelvic 
disorders  are  apt  to  occur  owing  to  de- 
ficient support  of  the  uterus,  lack  of 
tone  in  its  muscular  elements.  Leucor- 
rhea  is  also  frequent,  owing  to  relaxa- 
tion of  the  glandular  elements  of  the 
whole  genital  tract.  Such  women  con- 
ceive readily,  but  abortion  is  very  fre- 
quent among  them ;  if  the  fetus  is 
carried  to  the  normal  period,  they  have 
little  or  no  milk.  Children  born  of 
such  mothers  make  up  the  largest 
number,  if  not  all,  the  cases  of  cretin- 
ism, rickets,  harelip,  cleft  palate,  and 
other    malformations    usually   ascribed 


712 


ANIMAL   EXTRACTS    (SAJOUS). 


to  hereditary  influence.  We  are  deal- 
ing simply  with  deficiency  of  the  iodine 
in  organic  combination  which  the 
thyroparathyroid  glands  supply  to  the 
organism  to  sustain  their  intrinsic 
metabolism,  i.e.,  their  vital  activity. 

If  the  mother  has  at  her  disposal  suf- 
ficient store  of  thyroid  secretion,  the 
child  does  well;  but  if  there  is  thyroid 


equilibrium  being  established ;  but  in 
girls  menstruation  is  late  in  being  estab- 
lished; uterine  retroflexion  is  frequent; 
the  chest  is  undeveloped. 

The  author  has  often  seen  women 
nearing  40  years  of  age  who  are  fat 
and  whose  menstrual  flow  is  excessive 
take  thyroid  extract  in  order  to  reduce 
their  obesity.  He  has  often  seen  the 
menstrual  flow  in  these  women  become 


Adipositas  (8  months  old).    Weighs  36  pounds.    {Sheffield.) 


insufficiency,  and  especially  if  to  this 
fault  be  added  tuberculosis,  hereditary 
syphilis,  alcoholism,  inanition,  saturn- 
ism, or  diabetes,  the  child  will  show  un- 
doubted signs  of  these  taints,  and  will 
probably  be  a  myxedematous  cretin, 
with  signs  of  rickets  and  achondro- 
plasia, and  to  this  cause  may  be  assigned 
such  malformations  as  harelip,  cleft 
palate,  bony  deformities,  hypospadias, 
or  undescended  testicle.  Should  the 
maternal  taint  be  but  slight,  the  child 
will  merely  be  very  backward,  which  is 
a  matter  of  small  amount  in  boys,  and 
if  after  a  time  righted  by  the  thyroid 


modified,  their  stoutness  decrease,  and 
the  women  find  themselves  pregnant, 
when  they  had  for  a  long  time  given  up 
all  hope  of  ever  being  so  again.  He  has 
often  by  means  of  thyroid  extract 
brought  to  a  successful  end  a  preg- 
nancy in  women  who  have  repeatedly 
miscarried.  It  is  often  noticed  that 
in  adults  incontinence  of  the  urine 
can  be  stopped  by  rest  in  bed.  This 
comes  about  from  the  fact  that,  while 
resting  in  bed,  the  patient  is  subject- 
ing his  tissues  to  large  doses  of  thy- 
roid secretion.  In  the  case  of  a 
pregnant     woman     the     increase     of 


ANIMAL  EXTRACTS    (SAJOUS). 


713 


thyroid  secretion  often  becomes  excess- 
ive during  the  pregnancy,  and  the 
woman  suffers  froui  the  symptoms  of 
excessive  tliyri^id  si-eretidu.  Hertoghe 
(Bull,  de  I'Acad.  R.nalc  de  Med.  Bcl- 
giquc,  April  27,  1907). 

Thyroid  insufficiency  is  the  cause  of 
many  of  the  phenomena  noted  in  young 
infants,  such  as  a  tendency  to  obesity, 
to  transient  edema,  cold  feet  and  hands, 


experience  infants  became  myxedema- 
tous when  the  mothers  had  goiter.  In 
other  cases,  the  healthy  infants  of 
liealtliy  parents  became  myxedematous 
when  they  had  a  wet-nurse  with  goiter. 
All  these  children  were  cured  with 
thyroid  treatment  and  change  of  nurse. 
Experimental  research  with  goats  has 
confirmed  the  fact  of  transmission  of 
thyroid  secretion  by  the  placenta  and  in 


Adipositas.    Same  case,  back  view.    (Sheffield.) 


scanty  and  brittle  hair,  vasomotor  dis- 
turbances, vomiting,  somnolency,  and 
slight  resistance  to  infections.  With 
artificial  feeding,  these  signs  become 
more  pronounced,  with  eczema,  urti- 
caria, tardy  dentition,  etc.  It  seems  evi- 
dent that  nurslings  receive  in  mother's 
milk  some  of  the  products  of  the 
mother's  thyroid  functioning.  The 
physiological  hypothyroidism  of  the  new- 
born may  assume  pathological  propor- 
tions ;  any  derangement  in  thyroid 
functioning  on  the  part  of  the  mother 
or  wet-nurse  may  lead  to  severe  symp- 
toms of  hypothyroidism  in  the  infant. 
In    several    instances    in    the    writer's 


the   milk.      Concetti    (Annales   de  med. 
et  chir.  mfantiles,  Aug.  15,  1909). 

The  rudimentary  forms  of  myx- 
edema or  hypothyroidism  in  children 
are  particularly  liable  to  escape  recog- 
nition, while  thyroid  treatment  in 
time  is  almost  a  certain  cure.  In  a 
case  of  this  kind  a  boy  of  6  had  not 
grown  in  the  last  two  years,  but 
seemed  otherwise  normal,  although 
not  particularly  bright.  Under  cau- 
tious thyroid  treatment  by  the  end 
of  eighteen  months  he  had  grown  11 
cm.,  nearly  4^  inches.  In  2  other 
cases  the  myxedema  developed  after 
severe  measles  or  mumps,  with  acute 


714 


ANIMAL  EXTRACTS    (SAJOUS). 


thyroiditis  in  the  latter  case.  The 
thyroid  treatment  ordered  was  soon 
abandoned  by  the  family,  and  the  child 
developed  pronounced  myxedema,  but 
after  two  years  it  spontaneously  sub- 
sided. In  a  fourth  case  the  myxedema 
developed  after  a  severe  fall  over  a 
balustrade,  the  throat  in  front  bleeding 
from  the.  injury.  Thyroid  treatment 
promptly  cured  the  child.  "Pasty" 
children,  fat,  pale,  and  flabby,  may  be 
suffering  from  hypothyroidism  and  re- 
quire thyroid  treatment.  Stoeltzner 
(Jahrbuch  fiir  Kinderheilkunde,  Aug., 
1910). 

Diagnosis  in  the  early  stage  of  the 
malady  must  be  very  largely  a  matter 
of  exclusion  and  experiment.  The  pa- 
tient comes  complaining  of  debility,  lack 
of  energy,  is  chilly,  the  skin  is  dry,  so 
also  the  hair,  ideation  is  slow,  the  tem- 
perature may  be  subnormal  and  asso- 
ciated with  a  slow  pulse  rate.  His 
complaint  is  chiefly  regarding  his  weak- 
ness and  lack  of  energy.  If  thyroid 
deficiency  be  at  the  bottom  of  the 
patient's  trouble  the  administration  of 
thyroid  tablets  three  times  a  day  for  a 
short  period  will  produce  marked  and 
continuous  improvement.  W.  B.  Thistle 
(Can.  Pract.  and  Rev.,  June,  1910). 

Hypothyroidia,  in  so  far  as  nutri- 
tion is  concerned,  may  be  defined, 
therefore,  as  that  condition  of  the  body 
in  which,  owing  to  deficient  production 
of  the  thyroparathyroid  secretion,  cel- 
lular metabolism  is  slowed  sufficiently 
to  inhibit  more  or  less  all  functions. 
Hence,  the  value  of  thyroid  prepara- 
tions in  infantile  marasmus. 

In  infantile  wasting  the  writer  gives 
thyroid  in  a  diluted  milk  and  cream 
mixture  with  sodium  citrate,  1  or  2 
grains  to  the  ounce  of  milk.  In  a  day 
or  two  cream  is  gradually  added,  Yz  a 
teaspoonful  to  the  feeding  bottle.  Out 
of  80  cases  thus  treated  72  were  infants 
under  9  months  and  their  history  was 
simply  one  of  wasting.  TLe  other  8  had 
a  wasting"  supervening  on  some  acute 
diseases ;  63  cases  did  well ;  5  cases 
presented  syphilitic  histories  in  which 
wasting  was  a  marked  symptom.     Mer- 


cury was  first  given  and  later  thyroid. 
Three  immediately  gained  and  event- 
ually recovered.  In  older  children  the 
results  have  also  been  favorable,  ex- 
cept when  tuberculosis  was  present.  In 
children  under  9  months,  the  author 
began  with  %  grain  of  dried  thyroid 
once  daily.  Larger  doses  often  seemed 
to  induce  a  diarrhea.  In  the  giving  of 
thyroid  it  is  advisable  to  test  the  stools 
frequently  to  see  whether  they  are  acid 
or  alkaline.  In  case  acidity  is  found 
the  bicarbonate  of  soda  may  be  given 
three  times  daily,  and  when  the  natural 
alkalinity  of  the  stools  is  restored  the 
thyroid  will  begin  to  exert  its  beneficial 
results.  No  grave  symptoms  followed 
the  thyroid  therapy.  In  6  cases  a 
punctiform  rash  appeared,  confined  in  2 
cases  to  the  front  of  the  chest.  It  was 
evanescent  and  disappeared  without 
treatment  in  the  course  of  twelve  to 
twenty-fovir  hours.  In  only  1  case  was 
it  necessary  to  stop  the  thyroid  (three 
days)  in  order  to  cause  the  rash  to  dis- 
appear. J.  W.  Simpson  (Brit.  Med. 
Jour.,  April  30,  1910). 

The  wide  range  of  usefulness  of  thy- 
roid extract  as  a  regulator  of  metabolic 
processes  is  not  sufficiently  recognized 
by  the  profession.  The  writer  has  seen 
several  marasmic  infants  transformed 
into  normal,  healthy  babies  under  use 
of  thyroid,  and  in  these  cases  it  was 
necessary  to  use  it  for  only  a  short 
time,  the  gland  seeming  to  have  been 
stimulated  to  increased  functional  activ- 
ity by  the  use  of  the  extract. 

Its  administration  to  mothers  who 
have  not  enough  milk  for  their  babies 
has,  in  the  writer's  practice,  with  one 
exception,  been  followed  by  an  increase 
in  the  flow,  making  it  possible  to  get 
along  without  artificial  feeding  where 
such  feeding  had  been  necessary  with 
former  children  and  would  have  been 
necessary  in  these  cases,  as  shown  by 
decreased  flow  whenever  the  thyroid 
was  withheld.  E.  W.  Demaree  (West- 
ern Med.  Rev.,  May,  1910). 

In  contrast  with  this  condition,  and 
exemplifying  clearly  what  we  are  to 
expect  from  thyroid  preparations,  is 
the  opposite  condition,  that  of 


A^riMAL   EXTRACTS    (SAJOUS). 


m 


Hyperthyroidia,  or  Hyperthyroid- 
ism.— The  opinion  of  Mobius  that  ex- 
ophthahiiic  goiter  or  Graves's  disease 
is  due  to  overactivity  of  the  thyroid 
has  steadily  gained  the  confidence  of 
the  profession  in  recent  years.  But 
this  imposes  the  necessity  of  estabhsh- 
ing  clearly  the  diagnosis  of  this  dis- 
ease, for  there  are  many  disorders  that, 
are  due  to  thyroid  overactivity,  the  so- 
called  "larval"  or  "aberrant"  types, 
the  "formes  frustes"  of  the  French, 
or  "pseudo-Graves's"  disease,  which 
should  not  be  confounded  at  all  with 
true  exophthalmic  goiter,  since  the  ac- 
tive or  erethic  stage  of  the  latter  is 
aggravated  by  the  use  of  thyroid  prep- 
arations, while  the  "pseudoforms"  are 
benefited  by  these  agents.  This  does 
not,  however,  militate  against  the  fact 
that  exophthalmic  goiter  and  all  the 
above-mentioned  subtypes  are  expres- 
sions of  thyroid  overactivity,  or  hyper- 
thyroidism. In  all  we  meet,  more  or 
less  defined — in  proportion  with  excess 
of  thyroid  secretion  produced — the 
same  group  of  phenomena,  all  of  which 
can  readily  be  explained  by  excessive 
tissue  metabolism  and  its  consequences. 

The  early  diagnosis  of  hyperthy- 
roidism will  be  aided  by  discard- 
ing such  terms  as  Parry's  disease, 
Graves's  disease,  Basedow's  disease, 
and  exophthalmic  goiter  and  substi- 
tuting in  discussion  and  in  print  the 
more  natural  term,  hyperthyroidism, 
and  by  remembering  (1)  that  so- 
called  cardinal  signs  are  usually  late 
signs  in  the  development  of  hyper- 
thyroidism; (2)  that  in  the  beginning 
of  hyperthyroidism  its  manifestations 
are  apt  to  be  monosymptomatic  and 
during  this  period  the  symptoma- 
tology is  characterized  by  inconstancy 
and  variability;  (3)  that  a  change  in 
the  nervous  and  mental  state  is  the 
ever-present  symptom  and  sign  of 
hyperthyroidism;  that  this  is  fre- 
quently   the    only    complaint    in    the 


beginning,  and  that  a  more  intensive 
study  of  the  whole  individual  sup- 
posed to  be  suffering  from  so-called 
hysteria  or  neurasthenia  will  fre- 
quently disclose  other  symptoms  and 
signs  of  hyperthyroidism,  and  (4) 
that  the  fundamental  source  of  error 
in  the  recognition  of  hyperthyroidism 
is  rather  in  not  looking  than  in  not 
knowing.  W.  W.  Graves  (Jour.  Mo. 
State  Med.  Assoc,  Sept.,  1911). 

As  is  the  case,  in  other  words,  when 
excessive  doses  of  thyroid  preparations 
are  administered,  there  occurs :  a  rise 
of  temperature,  a  feeling  of  abnormal 
warmth ;  tachycardia  due  to  excessive 
excitability  of  the  heart  muscle ;  pains, 
trembling  owing  to  a  similar  condition 
of  all  muscles ;  sweating  due  to  over- 
activity of  the  sweat  glands ;  vomiting 
and  diarrhea  owing  to  abnormal  irri- 
tability of  their  gastric  and  intestinal 
neuromuscular  supply.  Excessive  me- 
tabolism involving  the  production  of  a 
surplus  of  wastes,  the  kidneys  are 
overburdened  and  overactive,  and  the 
cutaneous  emunctories  likewise,  the  lat- 
ter causing  pruritus  and  a  papular 
eruption,  beginning,  as  a  rule,  over  the 
scapulas.  As  in  Graves's  disease,  hyper- 
thyroidism and  excessive  doses  of  thy- 
roid may  produce  apparent  protrusion 
of  the  eyeballs,  the  palpebral  muscles 
being  retracted  owing  to  their  abnormal 
contractility. 

Case  of  a  woman  who  for  fifteen 
years  had  had  a  slight  enlargement  of 
the  thyroid  which  never  gave  incon- 
venience. Some  one  advised  her  to  take 
thyroid  extract,  and  she  took  daily  5- 
grain  tablets  for  over  three  months. 
After  some  weeks'  medication  she  be- 
gan to  notice  trouble  about  the  heart. 
When  examined  she  had  a  pulse  of  140. 
Notwithstanding  this  tachycardia,  the 
heart  sounds  were  perfectly  normal,  and 
there  was  no  enlargement  of  the  organ. 
She  showed  the  characteristic  fine  tre- 
mor of  Graves's  disease. 


71-6 


Animal  extracts  (sAjous). 


The  thyroid  extract  was  at  once  dis- 
continued, and  a  week  later  the  pulse 
had  dropped  from  140  to  110  and  the 
tremor  was  distinctly  less.  Eight  days 
later  the  tremor  had  entirely  disap- 
peared, and  the  patient  had  no  further 
trouble,  though  her  pulse  kept  up  to 
100.  G.  J.  Preston  (Maryland  Med. 
Jour.,  Dec.  10,  1898). 

Thyroidism  in  an  infant  from  ad- 
ministration of  thyroid  extract  to  the 
mother,  a  woman  aged  34  who  had 
exophthalmic  goiter.  On  December  24th 
thyroid  extract  (two  S-grain  tabloids 
daily)  was  administered  to  the  mother. 
On  January  Ist  the  child  had  been 
sweating  profusely  for  several  nights 
It  was  looking  ill  and  was  sleepless.  It 
had  vomited  every  morning  for  three 
days.  The  extract  was  consequently 
stopped  for  five  days.  The  child  im- 
mediately improved,  and  on  January  4th 
was  quite  well.  On  the  9th,  thyroid 
extract  was  again  given  to  the  mother. 
The  next  day  the  child  vomited,  was 
again  restless,  did  not  look  well,  and 
sweated  profusely,  etc.  The  child  was 
weaned  and  after  this  remained  per- 
fectly well.  B.  Bramwell  (Lancet, 
March  18,  1899). 

The  administration  of  thyroid  gland 
substance,  or  thyroid  extract,  is  capable, 
if  given  in  sufficient  amount,  of  inducing 
a  toxic  state  which  in  almost  every  es- 
sential is  similar  to  Graves's  disease. 
An  artificial  state  of  hyperthyroidism 
is  thereby  produced,  which  duplicates 
almost  in  full  the  morbid  syndrome. 
Even  the  characteristic  exophthalmic 
symptoms  have  been  observed  after 
thyroid  feeding  by  Auld,  Beclere,  and 
others,  and  Edmunds  was  able  to  induce 
proptosis,  widening  of  the  palpebral  fis- 
sure, and  dilatation  of  the  pupils  in 
six  monkeys  by  this  means,  even  after 
excision  of  a  portion  of  the  cervical 
sympathetic.  A.  R.  Elliott  (Amer. 
Jour.  Med.  Sci.,  Sept.,  1907). 

There  seem  to  be  two  distinct  types  of 
chronic  intoxication  from  perverted  thy- 
roid functioning,  one  depending  on  the 
sympathetic  system  and  the  other  on 
the  vagus  system.  In  exophthalmic 
goiter  the  two  types  may  be  combined ; 


the  vagus  type,  predominates  during  the 
remissions  and  the  sympathetic  type  pre- 
dominates during  the  exacerbations. 
The  sympathetic  hyperthyroidism  is  the 
primary,  the  vagus  type  being  more  of 
a  secondary,  compensating  process,  but 
it  may  assume  the  preponderance  in 
time.  The  morbid  functioning  of  the 
thyroid  which  entails  this  modification 
in  the  tone  of  these  antagonistic  nerve 
systems  may  be  the  result  of  infectious 
or  bacteriotoxic  influences.  There  may 
be  isolated  patches  in  the  thyroid  in 
which  the  secretion  is  perverted,  while 
the  balance  may  be  sound ;  this  would 
explain  the  cases  in  which,  after  re- 
moval of  parti  of  the  enlarged  thyroid, 
severe  acute  symptoms  of  hyperthy- 
roidisin  developed.  Kostlivy  (Mitt.  a. 
d.  Grenz.  gebietend.  Med.  u.  Chir.,  Bd. 
xxi,  Nu.  4,  1910). 

For  several  years  the  writer  has  been 
seeing  cases  of  hyperemic  thyroid,  or 
thyroid  hyperemia,  and,  upon  consulting 
reference  textbooks,  found  pediatric 
literature  quite  barren  of  comment  on 
this  affection.  The  condition  arises  at 
puberty,  and  all  cases  seen  by  the  writer 
have  been  girls.  The  usual  history  is 
that  the  patient  has  grown  rapidly,  has 
been  busy  at  school,  has  been  observed 
to  be  nervous,  and  then  the  discovery 
is  made  that  the  collar  worn  is  unduly 
tight.  An  examination  reveals  a  swol- 
len neck,  and  the  patient  is  brought  to 
the  physician.  The  gland  is  found  to 
be  symmetrically  enlarged,  occasionally 
the  right  lobe  slightly  in  excess ;  the 
gland  is  firm,  but  yielding;  no  bruit  is 
felt  or  heard.  There  is  usually  a  mod- 
erate simple  anemia.  There  may  or 
may  not  be  a  tachycardia.  The  pa- 
tient is  markedly  nervous ;  there  may 
be  a  slight  tremor.  In  2  cases  seen  there 
seemed  to  be  a  tendency  to  exophthal- 
mos and  the  entire  clinical  picture  was 
that  of  a  mild  exophthalmic  goiter,  yet 
recovery  was  prompt,  there  was  no  re- 
turn of  the  disease,  and  the  resemblance 
to  Parry's  disease  was  in  the  end  only 
a  simulation.  This  transient  hyperthy- 
roidism, which  in  adults  may  be  seen 
at  menstruation,  during  pregnancy,  and 
in  sexual  excitement,  is  in  reality  more 
or  less  physiological  and  represents  the 


ANIMAL  EXTRACTS    (SAJOUS). 


717 


overresponse  of  the  thyroid  gland  to 
the  stimulation  of  altered  nerve  activity, 
and,  in  the  cases  above  mentioned,  to 
the  special  altered  internal  secretions 
manifest  at  puberty.  Demme  and  other 
French  internists  describe  this  as 
"school  goiter,"  and  a  variety  occurring 
in  warm  weather  and  occasioned  in  part 
by  the  wearing  of  constricting  collars, 
as  "summer  goiter"  and  "garrison 
goiter." 

The  course   of  thyroid  hyperemia  is 


ministered  as  required.  Small  doses 
of  arsenic  exert  a  retarding  influence 
on  the  overactive  gland.  F.  B.  Cross 
(Long  Island  Med.  Jour.,  Apr.,  1910). 

With  the  pathogenesis  of  these  two 
syndromes  clearly  defined,  the  various 
disorders  in  which  thyroid  prepara- 
tions are  indicated  suggest  themselves, 
viz.,  those  in  which  any  of  the  signs  of 
hypothyroidism  are  more  or  less  dis- 


ease of  cretinism.      Result  of  four  months'  treatment.     Growth,  4  inches.     Intellect 
approaching-  normal.    (Moore.) 


short.  With  proper  treatment  the  con- 
dition should  disappear  in  a  few  weeks 
or  months,  and  in  some  cases  the  sub- 
sidence of  the  disease  appears  to  be 
spontaneous,  having  no  relation  to  the 
treatment  pursued. 

The  treatment  is  largely  a  matter  of 
hygiene.  A  rest  from  school  activ- 
ities; life  in  the  open  air,  preferably 
in  the  country;  good  nourishing  food, 
a  change  in  the  drinking  water,  and 
an  avoidance  of  nervous  excitement 
are  the  prominent  features  of  the 
treatment.  The  anemia  should  be 
corrected    and    nerve    sedatives    ad- 


cernible.  The  pathogenesis  of  hyper- 
thyroidism being  also  apprehended,  the 
limitations  of  thyroid  treatment  also 
appear:  the  doses  utilized  should  be 
adjusted  in  each  case  to  the  degree  of 
hypothyroidism  that  is  present. 

Cretinism. — This  condition  repre- 
sents the  extreme  type  of  hypothyroid- 
ism in  the  young.  The  value  of  thyroid 
gland  is  such  in  this  distressing  disor- 
der that  it  may  be  regarded  as  a  specific 
— the  only  agent,  in  fact,  which  influ- 
ences it  at  all.    The  earlier  it  is  used, 


718 


ANIMAL   EXTRACTS    (SAJOUS). 


however,  the  better  the  results;  hence, 
the  importance  of  early  signs  of  the  dis- 
ease, the  most  prominent  of  which  are 
in  infants  (see  article  on  "Cretinism"), 
enlargement  of  the  tongue  and  of  the 
thyroid,  myxedematous  swelling,  arrest 
of  growth,  delay  in  learning  to  speak 
and  walk,  relative  deficiency  of  intelli- 
gence, dryness  and  scaliness  of  the  skin, 
scantiness  of  the  eyebrows  and  eye- 
lashes, pufBness  of  the  lids,  and  facies 
of  old  age. 

The  enlargement  of  the  tongue  and  of 
the  thyroid  are  the  most  positive  signs 
of  cretinism  in  the  infant.  The  shape 
of  the  nose  and  the  complexion  are  not 
characteristic  at  this  early  stage,  and 
.  the  myxedematous  swellings  are  not  ob- 
served until  after  the  end  of  the  first 
year.  Early  diagnosis  of  acquired 
cretinism  is  still  more  difficult.  Back- 
wardness in  learning  to  walk  and  talk 
is  the  most  reliable  sign.  In  the  en- 
demic regions  the  parents  are  now 
being  educated  to  watch  for  the  early 
signs.  Von  Jauregg  (Wien.  klin. 
Woch.,  Jan.  10,  1906). 

Soon,  sometimes  within  a  few  days, 
the  effects  of  whatever  preparation  is 
used  begin  to  appear :  the  appetite  in- 
creases, the  temperature  rises,  and, 
nitrogenous  foods  being  more  perfectly 
assimilated,  the  nitrogen  excretion  rises 
— sometimes  beyond  that  ingested. 
There  is  loss  of  weight  owing  to  ab- 
sorption and  excretion  of  the  excess  of 
fluids  in  the  tissues — an  effect  accom- 
panied by  marked  thirst — in  some 
cases,  as  observed  by  Marie,  and  in- 
creased activity  of  the  kidneys.  The 
red  corpuscles  and  hemoglobin  are 
simultaneously  increased. 

The  wrinkles  and  edema  disappear; 
the  harsh,  dry  skin  becomes  soft, 
smooth,  and  moist;  the  hair  from 
coarse  and  thin  becomes  thick  and  fine. 
Growth  is  resumed,  and  proceeds  with 
great  rapidity  in  children,  sometimes  at 


the  rate  of  one  inch  per  month.  They 
do  not,  as  a  rule,  however,  grow  tall. 
The  brain  responds  more  slowly,  but 
considerable  intelligence  is  gained  in 
most  instances,  at  times  even  that  of 
an  average  child.  The  later  in  life 
cretinism  develops,  the  better  are  the 
chances  of  improvement  in  this  direc- 
tion ;  occasionally  none  is  observed.  In 
other  particulars,  all  degrees  of  cretin- 
ism, especially  in  sporadic  cases,  may 
be  said  to  be  improved,  the  best  results 
being  obtained  in  young  children. 

Series  of  nearly  100  cases  in  which 
three  years  and  more  have  passed  since 
treatment  was  commenced.  All  degrees 
of  cretinism  and  all  ages  were  unmis- 
takably benefited  by  the  treatment,  but 
the  best  results  were  obtained  with  the 
younger  children.  Complete  cure  was 
the  rule  in  the  milder  cases,  without 
serious  impairment  of  the  hearing,  when 
treatment  was  begun  in  early  infancy 
(at  6  weeks  in  1  case).  Von  Jauregg 
(Wien.  klin.  Woch.,  Jan.  10,  1906). 

Since  1905,  the  Austrian  government 
has  been  supplying  thyroid  tablets  free 
of  charge  in  seven  endemic  foci  of 
cretinism  with  medical  inspection 
twice  a  year.  About  108,600  tablets 
were  thus  distributed  in  1907,  and 
157,900  in  1908;  the  number  of  persons 
taking  them  was  1011,  and  603  were 
still  under  the  thyroid  treatment  at 
the  close  of  1908.  The  results  are 
tabulated  under  various  headings, 
special  attention  being  paid  to  the 
increase  in  height  as  the  most  certain 
index  of  the  benefit  derived.  Other 
findings  are  more  liable  to  be  in- 
fluenced by  subjective  impressions. 
The  report  states  that  the  results 
have  been  extremely  satisfactory, 
confirming  the  efificacy  of  thyroid  treat- 
ment as  a  prophylactic  measure,  espe- 
cially in  endemic  foci  of  cretinism.  In 
677  cases  followed  to  date  marked 
improvement  was  obtained  in  48.6  per 
cent,  and  only  8.6  per  cent,  showed  no 
benefit  from  the  course.  The  most 
striking  proof  of  the  beneficial  influence 
of  thyroid  treatment  on  the  growth  iis 


ANIMAL   EXTRACTS    (SAJOUS). 


719 


the  fact  that  in  2i1T ,  that  is,  85.7  per 
cent,  of  all  cases,  the  former  dwarf 
cretin  children  grew  to  be  taller  than 
the  normal  standard  for  their  age.  As 
a    rule,    treatment     was     restricted    to 


growing  power  of  the  preceding  years 
had  been  held  in  reserve,  until  suddenly 
released  by  the  thyroid  treatment,  when 
it  made  all  its  force  felt  in  a  relatively 
short  period.     A  large   number  of  the 


Thyroid  extract  in  cretinism.  Cretinic  idiot,  7  years  old  when  thyroid  treatment  was  begun. 
Had  ceased  to  develop  when  3  years  old.  Changes  after  one  year's  treatment.  Growth  6)^  inches. 
(J".  B.  McQee :    Cleveland  Medical  Gazette,  December,  1900. ) 


school  children :  the  oldest  cretin  wa? 
26  years  old.  Even  after  20  a  number 
of  the  cretins  grew  much  taller  and  the 
other  symptoms  of  cretinism  became 
attenuated.  This  growth  at  this  age  is 
so   surprising  that   it   seems   as   if  the 


more  interesting  cases  are  cited  in  de- 
tail. One  cretin,  20  years  old,  grew  11 
cm.,  but  then  refused  to  continue  treat- 
ment, as  he  outgrew  his  clothes  too  fast 
He  did  not  lose  his  milk  teeth  until 
after  thyroid  treatment  was  commenced. 


720 


ANIMAL   EXTRACTS    (SAJOUS). 


although  those  of  the  second  dentition 
were  in  place.  A.  von  Kutschera 
(Wiener  klin.  Woch.,  June  3,  1909; 
Jour.  Amer.  Med.  Assoc,  July  17, 
1909). 

Case  illustrating  the  far-reaching 
importance  of  the  thyroid  for  the  physi- 
cal and  mental  growth  and  development 
and  the  lack  of  both  with  lack  of  thy- 
roid functioning.  The  child  was  born 
with  typical  pure  myxedema  and  at 
the  age  of  4  looked  still  like  a  10 
months'  babe,  being  a  pronounced 
idiot.  No  traces  of  the  thyroid  could 
be  discovered  on  palpation.  Thyroid 
treatment  was  then  commenced,  and 
in  three  months  the  child  was  trans- 
formed under  its  influence;  it  had 
grown  10  cm.  in  height,  and  has  de- 
veloped normally  since,  and  is  now 
lively  and  healthy.  C.  Doderlein 
(Norsk  Mag.  f.  Laegevidenskaben,  July, 
1910). 

To  obtain  such  results,  however,  it 
is  important  to  distinguish  true  cretins 
from  idiotic  dwarfs  in  whom  thyroid 
is  less  beneficial  or  of  no  benefit  what- 
ever. These  are  the  mongol  or  kal- 
muck  idiots  and  the  micromelic  or 
achondroplasic  dwarfs. 

Mongol  or  kalmuck  idiots  resemble 
cretins  in  many  particulars.  The 
mouth  is  kept  open  by  the  protruding 
and  thickened  tongue ;  the  hair  is  dry, 
scarce,  and  coarse ;  the  palatal  arches 
are  narrow,  the  development  of  the 
teeth  is  delayed,  constipation  is  the 
rule,  umbilical  hernia  is  frequent,  etc. 
But  their  skin  is  less  rough,  and  the 
general  development  is  less  retarded, 
though  that  of  the  brain,  judging  from 
the  degree  of  idiocy,  must  differ  but 
little  from  that  of  a  cretin's.  In  this 
class  of  idiots  the  palpebral  fissures  are 
narrow  and  slope  upward  from  the 
nose;  the  epicanthus  projects  markedly 
over  the  inner  canthus,  as  is  the  case 
in  most  Chinese.  Nystagmus,  i.e.,  os- 
cillatory movements  of  the  eyeballs,  is 


also  common.  Thyroid  treatment^ 
though  much  less  beneficial  than  in 
cretins,  is,  nevertheless,  productive  of 
good.  The  mental  torpor  is  somewhat 
improved,  the  constipation  and  hernia 
are  counteracted,  and  all  functions 
seem  to  be  activated. 

Achondroplasic  dwarfs  are  in  reality 
but  cases  of  fetal  rickets,  are  normal 
as  to  intelligence,  but  their  face  is  that 
of  the  cretin,  the  skin,  especially  about 
the  hands,  also  recalling  that  of  the  lat- 
ter. Other  physical  abnormahties  are 
abnormal  shortness  and  deformity  of 
the  limbs,  marked  narrowing  of  the 
palatal  arch,  and  delay  in  the  closure  of 
the  fontanelles.  This  condition,  essen- 
tially due  to  morbid  development  of 
the  bones  and  cartilages,  is  in  no  way 
influenced  favorably  by  the  use  of  thy- 
roid preparations. 

The  dose  should,  of  course,  vary 
with  the  age  of  the  patient  from  % 
grain  (0.015  Gm.)  by  the  mouth  in  a 
1 -year-old  child  to  3  grains  (0.2  Gm») 
in  the  adult.  As  tolerance  varies, 
especially  in  children,  small  doses 
should  be  used  at  the  start  and  very 
gradually  increased  until  not  more 
than  1%  grains  (0.1  Gm.)  of  desiccated 
thyroid  in  a  child  and  9  grains  (0.6 
Gm.)  in  an  adult  are  given  in  divided 
doses  daily.  There  is  no  condition  in 
which  the  prevailing  empirical  method 
of  administering  remedies  should  be 
more  rigidly  guarded  against  than  in 
this,  since  excessive  doses  of  thyroid 
not  only  inhibit  its  beneficial  effects  by 
exciting  violent  catabolism,  thus  break- 
ing down  the  tissues  instead  of  build- 
ing them  up  gradually,  but  they  may,  by 
doing  so,  cause  death. 

[What  unfavorable  results  have  been  re- 
corded can  usually  be  ascribed  to  excessive 
doses.  A  certain  critical  author  remarks,  for 
instance,  referring  to  personal  experience  of 


ANIMAL   EXTRACTS    (SAJOUS). 


721 


this  sort :  "There  was  no  longitudinal 
growth  of  the  bones  nor  any  poisoning  to  be 
observed,  but  great  bodily  prostration  and 
an  augmentation  of  mental  apathy,  together 
with  emaciation  dependent  upon  a  loss  of 
fat.  From  these  unfavorable  results  of 
therapy  it  is  seen  that  the  view  is  untenable 
that  athyreosis  is  the  cause  of  cretinism. 
These  observations  are  the  reverse  of  the 
favorable  ones  made  on  the  treatment  of 
myxedema  by  thyroid  gland,  both  in  the 
young  .and  in  adults."  The  great  bodily 
prostration,  emaciation,  increase  of  apathy, 
etc.,  speak  for  themselves.  They  had  been 
caused  by  the  excessive  doses  the  critic  had 
administered.     C.  E.  de  M.  S.] 

The  doses  in  which  thyroid  extract 
is  usually  prescribed  are  many  times 
too  large.  The  ordinary  dose  is 
officially  quoted  as  from  3  to  10 
grains.  There  are  very  few  people, 
except  certain  types  of  lunatics,  who 
will  tolerate  such  doses  under  any 
circumstances,  and  not  even  they  are 
able  to  do  so  unless  this  dose  is 
arrived  at  by  a  gradual  increase  from 
small  beginnings.  It  is  a  clinical  fact, 
well  recognized  by  those  who  have 
any  real  experience  in  the  use  of  the 
drug,  that,  the  more  the  patient  re- 
quires thyroid  extract,  the  smaller 
should  be  the  initial  dose.  Since  the 
writer  has  been  using  it  he  has  been 
driven  back  and  back  in  his  doses. 
He  now  seldom  begins  with  more 
than  %.  grain  three  times  a  day.  He 
never  prescribes  a  larger  dose  than 
5  grains  thrice  daily,  and  then  only 
in  pronounced  myxedema  after  sev- 
eral weeks'  treatment.  He  has  had 
many  patients  who  were  unable  to 
take  more  than  %o  grain  once  a  day, 
but  this  was  in  each  case  quite  suffi- 
cient completely  to  protect  them  from 
the  symptoms  of  which  they  origi- 
nally complained.  In  connection  with 
the  allotrophic  disease,  he  suggests 
that  the  prophylactic  dose  for  an 
adult  should  not  exceed  %o  grain 
three  times  daily,  and  that  %.  grain 
three  times  daily  is  quite  a  sufficient 
therapeutic  dose  to  start  with.  Leon- 
ard Williams  (Practitioner,  Nov., 
1911). 


The  danger  signals  are  those  of  hy- 
perthyroidism, previously  described, 
the  principal  of  which  are  an  increase 
of  temperature  beyond  normal,  tachy- 
cardia, digestive  disturbances,  dyspnea, 
and  tremor.  When  any  of  these  phe- 
nomena appear,  the  dose  should  be 
reduced  until  the  temperature  becomes 
normal — w^hich  may  be  one  or  two  de- 
grees F.  above  the  hypothermia  usually 
observed  in  these  cases.  It  should  be 
remembered,  however,  that  excessive 
doses  may  also  cause  hypothermia  by 
inducing  collapse.  If  the  morbid  ef- 
fects continue,  the  use  of  the  remedy 
should  be  stopped  a  few  days  and  then 
resumed  with  a  sinaller  dose.  Should 
the  hyperthyroidism  persist  notwith- 
standing. Fowler's  solution  in  small 
doses  soon  arrests  it.  A  common  un- 
toward effect  is  bending  of  the  bones 
of  the  legs,  owing  to  softening  of  the 
bones.  The,  child  should  not  be  al- 
lowed to  go  about  too  much,  or  when 
bowing  of  the  legs  appears,  it  should 
be  placed  in  bed,  as  advised  by  Telford 
Smith. 

[This  is  explained,  from  my  viewpoint, 
by  the  action  of  the  thyroid  principle  upon 
the  phosphorus  contained  in  the  calcium 
phosphate,  which  plays  so  important  a  role 
in  giving  bone  its  solidity  and  rigidity.  This 
suggests  the  use  of  calcium  phosphate  as  an 
adjuvant  to  the  thyroid  to  compensate  for 
its  loss.  The  influence  of  the  thyroid 
secretion  upon  calcium  metabolism  has 
been  well  shown  by  the  researches  of  Par- 
hon,  Macallum,  and  others.    C.  E.  de  M.  S.] 

Case  of  tetany  following  an  acci- 
dental overdose  of  thyroid  extract  in 
a  girl  aged  3  years  who  presented 
stigmata  of  cretinism.  She  was  fat 
and  plump,  with  reddish,  somewhat 
cyanotic  cheeks  and  abundant  coarse 
hair.  The  anterior  fontanelle  was  not 
closed.  The  hands  and  feet  were 
.  cold  and  blue.  The  eyebrows  were 
scanty.  The  abdomen  was  protuber- 
ant,   but    there    was     no    umbilical 


1-46 


722 


ANIMAL   EXTRACTS    (SAJOUS). 


hernia.  There  was  marked  lordosis,  and 
the  tibiae  were  curved.  She  was  short 
in  stature,  and  unable  to  say  more  than 
two  or  three  words.  Mentally,  as  well 
as  physically,  she  was  deficient  and 
backward.  The  rectal  temperature  was 
95°.  Thyroid  extract,  1  grain  t.  i.  d., 
was  given,  and  the  dose  was  gradually 
increased  to  2j^  grains  t.  i.  d.  All  went 
well  for  a  month,  during  which  time 
she  became  more  active  and  very  mis- 
chievous. One  morning  she  secured  the 
box  containing  5  tablets,  each  of  5 
grains  of  the  extract,  and  swallowed 
the  whole.  She  "cried  and  screamed" 
a  great  deal  that  day.  Six  hours  after 
she  became  "stiff  and  convulsed."  A 
dose  of  castor  oil  was  given,  and  later 
some  bromide.  There  was  no  diarrhea. 
The  writer  saw  her  the  next  day ;  she 
was  stiff,  and  presented  pronounced 
signs  of  tetany.  The  eyes  and  limbs 
"twitched"  a  good  deal.  The  face  was 
very  red.  The  characteristic  "accouch- 
eur hand"  and  arched  feet  were 
typical.  The  fingers  and  wrists  were 
swollen,  and  moving  the  joints  made 
the  child  cry.  The  whole  of  each  limb 
and  the  back  were  stiff  and  painful. 
The  deep  reflexes  were  increased.  The 
pulse  was  very  quick,  and  the  child  was 
feverish.  She  was  unable  to  stand  or 
sit  without  support. 

The  treatment  was  suspended  for  a 
fortnight,  and  the  symptoms  gradually 
disappeared.  Then  34  grain  of  thyroid 
extract  was  given  t.  i.  d.,  increased  to 
%  grain.  During  the  week  after  re- 
suming the  drug  the  "accoucheur  hand" 
was  again  noticed.  The  dose  was  again 
reduced,  but  later  increased.  One 
month  later  a  slight  recurrence  of  the 
"accoucheur  hand"  compelled  reduction 
of  the  dose  of  thyroid.  Subsequently, 
though  on  continuous  treatment,  no  re- 
currence of  the  tetany  has  been  ob- 
served. G.  W.  R.  Skene  (Med.  Review; 
Antiseptic,  May,  1911). 

[In  the  above  case  the  toxic  dose  of 
thyroid  produced  excessive  catabolism  and 
an  accumulation  of  waste  products  in  the 
blood.  Hence,  the  tetany  which  is  also 
produced  when  deficiency  of  thyroid  also 
leads     to     accumulation     of     spasmogenic 


wastes  because  the  latter  are  not  submitted 
rapidly  enough  to  hydrolysis,  a  process 
for  which  the  thyroid  secretion  prepares 
the  wastes  by  sensitizing  them.  C.  E. 
DE   M.   S.] 

An  important  feature  of  the  thyroid 
treatment  of  cretinism  is  the  necessity 
in  practically  all  cases  of  continuing  it 
to  prevent  recurrence.  The  only  per- 
manent benefit  when  thyroid  is  discon- 
tinued is  the  skeletal  growth,  though 
the  original  morbid  phenomena  never 
return  with  the  same  intensity. 

Several  cretins  occasionally  occur  in 
the  same  family,  from  the  same 
mother,  long  intervals  between  births 
indicating  the  permanence  of  the  patho- 
genic influence  in  the  parent.  Herman 
H.  Sanderson  (Jour,  of  the  Mich.  State 
Med.  Soc,  April,  1906),  for  example, 
observed  3  cases  in  one  family,  the 
patients  being  21,  11,  and  8  years  of 
age,  respectively.  This  points  to  the 
need  of  administering  thyroid  to  the 
mother  after  the  birth  of  a  cretin,  and 
during  any  subsequent  pregnancy. 

Studies  and  experiments  in  the  re- 
gions in  which  hypothyroidism  and 
athyroidism,  which  are  known  to  cause 
idiocy,  prevail — several  mountainous 
districts  in  the  Alps  and  the  Karst 
Mountains  with  clay  and  lime  subsoil. 
With  the  writer's  research  as  a  basis 
for  work,  local  physicians  were  in- 
structed to  administer  thyroid  tablets 
to  certain  idiots  and  to  report  on  the 
results ;  124  persons  were  thus  placed 
under  observation.  In  80  per  cent,  a 
marked  improvement  was  obtained  in 
four  to  eleven  months,  under  adminis- 
tration of  quantities  of  36  to  100  Gm. 
(1  to  3  ounces)  of  thyroid  substance; 
12  per  cent,  showed  no  improvement 
within  one  year,  while  8  per  cent,  did 
not  tolerate  even  small  doses  well.  In 
nearly  all  cases  the  integument  became 
fairly  normal,  the  height  increased  a 
little,  and  the  intellectual  qualities  im- 
proved. Wagner  (Jour.  Amer.  Med. 
Assoc,  Feb.  6,  1909). 


ANIMAL   EXTRACTS    (SAJOUS). 


723 


Myxedema. — Thyroid  preparations 
are  no  less  efficacious  in  this  disease, 
which  typifies  hypothyroidism,  in  the 
achilt  than  in  cretinism,  of  which,  in 
fact,  this  disorder  is  the  prototype  in 
adults.  Here,  again,  we  obtain  those 
striking  changes  which  clearly  indicate 
that  the  remedy  replaces  in  the  organ- 
ism a  constituent  necessary  to  the  vital 
process  itself,  and  the  least  deficiency 
of  which  impairs  all  functions.  This  is 
further  shown  by  the  necessity  of  ad- 
ministering it  continuously,  year  in  and 
year  out,  as  in  cretinism,  to  prevent  re- 
currence. 

Under  the  influence  of  thyroid  prep- 
arations the  morbid  symptoms  disap- 
pear. The  dense,  swollen  tissues  rap- 
idly recede,  causing  loss  of  weight;  the 
projecting  abdomen  resumes  its  nor- 
mal contour;  the  skin  loses  its  rough- 
ness and  dryness ;  the  hair  grows  more 
or  less  abundantly;  the  face  loses  its 
coarse  and  expressionless  appearance, 
the  wax-yellow  color  of  the  skin  being 
replaced  by  a  normal  hue ;  the  cyanosis 
of  the  lips,  ears,  and  nose  disappears. 
Even  the  slow  and  monotonous  speech 
and  mental  torpor  are  promptly  done 
away  with,  and  if  the  case  happens  in 
an  adolescent  stunted  by  the  disease 
growth  is  resumed  and  progresses  rap- 
idly, as  in  cretinism,.  The  physiolog- 
ical action  is  precisely  that  defined  un- 
der the  preceding  reading,  since  we 
again  meet  with  a  rise  of  temperature 
and  all  the  phenomena  that  denote  in- 
creased metabolic  activity,  including  a 
marked  increase  in  the  urea  excretion. 
Menstruation,  frequently  suspended 
during  the  disease,  soon  returns.  The 
appetite  markedly  increases,  and  the 
patient  experiences  a  feeling  of  well- 
being. 

The  dose  generally  employed  in  this 
disease  is,  as  a  rule,  too  large ;  1  grain 


(0.065  Gm.)  of  desiccated  extract 
daily,  gradually  increased  until  2  grains 
(0.12  Gm.)  are  given  three  times  a  day. 
Even  smaller  doses  have  brought  about 
favorable  results. 

Case  of  myxedema  in  a  woman  of 
60.  Entire  recovery  of  the  patient 
was  obtained  under  thyroid  treatment 
on  the  principle  of  gradually  increas- 
ing doses,  commencing  with  doses  so 
small  as  to  have  actually  no  action 
or  next  to  none.  For  two  months 
the  daily  dose  was  only  0.5  eg.  (54 
grain),  and  then  1  eg.  (1^  grains) 
was  taken  and  continued  every  day. 
By  the  end  of  six  months  the  patient 
was  as  well  as  before  the  onset  of  the 
myxedema,  and  has  kept  well  during 
the  year  since,  still  continuing  her 
daily  dose  of  1  eg.  of  the  extract, 
representing  only  about  one-thirtieth 
of  a  lamb's  thyroid  gland.  Alsted 
(Hospitalstidende,  xlvii,  No.  50,  1904). 

Inasmuch  as  myxedematous  patients 
are,  as  a  rule,  more  susceptible  to  thy- 
roid preparations  than  normal  subjects, 
it  is  always  best  to  begin  with  small 
doses,  since  the  degree  of  activity  of 
the  patient's  own  thyroid,  though 
greatly  reduced,  is  an  unknown  quan- 
tity. The  presence  of  unexpected  ac- 
tivity is  the  main  underlying  cause  of 
the  so-called  "susceptibility"  often  met 
with,  a  very  small  dose  of  the  desic- 
cated thyroid  sufficing  in  such  patients 
to  raise  the  standard  of  thyroid  activity 
to  its  normal  level.  Again,  as  I  have 
shown  elsewhere  (see  "Internal  Secre- 
tions," 1st  ed.,  p.  1139,  1907),  there  is 
a  true  cumulative  action  of  the  thyroid 
secretion  (thyroiodase)  when  thyroid 
preparations  are  administered,  and 
there  comes  a  time  when  toxic  phe- 
nomena appear,  even  under  the  influ- 
ence of  very  small  doses.  The  tem- 
perature is  the  best  guide.  As  it  is  be- 
low normal  in  all  cases,  the  doses 
should  be  regulated  in  such  a  manner 
as  to  raise  it  to  normal,  reducing  them 


724 


ANIMAL   EXTRACTS    (SAJOUS). 


as  98.6°  F.  (37"  C.)  is  exceeded.  The 
quantity  required — usually  somewhat 
larger  in  winter  than  in  summer — by 
each  patient  may  thus  be  readily  de- 
termined while  avoiding  cumulative 
effects. 

In  some  cases  it  is  well  to  ascertain 
whether  a  low  blood-pressure  is  not 
perpetuating   the    peripheral    hypother- 


Fig.  1.— True  myxedema.  (Hertoghe:  Bul- 
letin de  I'Academie  Royale  de  Medecine  de 
Belgique.) 

mia  by  causing  the  blood  to  recede  to 
the  deeper  great  trunks.  This  may  be 
done  by  giving  strychnine  simulta- 
neously in  doses  of  ^o  grain  (0.0016 
Gm.)  three  times  daily.  By  stimulating 
the  vasomotor  center,  it  causes  the  ves- 
sels to  contract,  and  thus  to  project  the 
circulating  arterial  blood  into  the  pe- 
ripheral capillaries.  Strychnine,  more- 
over, as  shown  by  I.  N.  Love,  tends  to 
prevent  the  untoward  effects  of  thyroid 
preparations. 

An  important  feature  of  the  thyroid 


treatment  of  myxedema  is  that  the  pa- 
tients should  be  kept  in  bed  the  first 
few  weeks  and  not  allowed  to  get  up 
suddenly,  to  avoid  sudden  syncope — the 
cause  of  death  in  several  cases  on  rec- 
ord. This  precaution  is  especially  nec- 
essary in  aged  and  weak  patients  and 
quite  as  much  where  the  improvement 
is  rapid  as  in  less  favorable  cases.     As 


Fig.  2.— The  same  patient  after  thyroid 
treatment.  {Ilertoglie:  Bulletin  de  I'Acade- 
mie  Royale   de   Medecine   de  Belgique.) 

emphasized  by  Combe,  Seymour  Tay- 
lor, and  others,  alcohol  should  not  be 
used  during  the  treatment. 

Bourneville,  Lancereaux,  and  other 
clinicians  have  called  attention  to  the 
fact  that  symptoms  of  myxedema  do 
not  appear  in  infants  until  they  are 
weaned.  This  is  because  the  mother 
supplies  her  suckling  what  thyroid  se- 
cretion it  needs  to  satisfy  the  needs  of 
its  cellular  metabolism.  Thyroid  ad- 
ministered to  a  nursing  mother  is  also 
transferred   to  the   nursHng  in  such  a 


ANIMAL  EXTRACTS    (SAJOUS). 


m 


degree,  in  fact,  that  the  latter  may  pre- 
sent toxic  phenomena.  This  suggests 
additional  caution  when  the  remedy  is 
used  in  myxedematous  women  during 
pregnancy  and  lactation. 

Contraindications. — When  any  ady- 
namic cardiac  disorder  is  p^resent,  the 
initial  dose  should  he  very  small  and 
very  gradually  increased,  giving  digi- 
talis simultaneously  if  indicated  by  the 
cardiac  trouble.  When  angina  pec- 
toris accompanies  myxedema,  small 
doses  are  beneficial,  especially  if  the 
patient  is  placed  on  a  vegetable  diet. 

Occasionally  aged  subjects  fail  to 
respond  to  the  thyroid  treatment  alone, 
and  the  disease  progresses  until  mental 
aberration,  melancholia,  or  even  mani- 
acal disorders  supervene.  The  de- 
pressed forms  of  mental  disorder  are 
probably  due  to  the  low  blood-pressure 
which  characterizes  the  disease,  and 
which  the  thyroid  tends  to  increase. 
Strychnine  counteracts  this  untoward 
action,  however,  while  enhancing  the 
beneficial  effects  of  the  thyroid  prep- 
aration. 

Case  of  a  man  of  42  years,  treated 
with  thyroid  gland.  Speedy  improve- 
ment occurred,  and  in  a  few  weeks  all 
the  symptoms  disappeared,  the  weigjit 
diminishing  from  13  to  10  stone.  For 
several  years  he  has  taken  thyroid  gland 
regularly,  and  has  thereby  maintained 
a  nearly  normal  standard  of  health. 
Straitened  circumstances  then  pre- 
vented him  from  buying  thyroid  glands. 
A  fortnight  after  their  deprivation  sev- 
eral of  the  original  symptoms  returned, 
and  in  less  than  two  weeks  thereafter 
nearly  a  complete  picture  of  myxedema 
was  reproduced,  with,  however,  scarcely 
so  advanced  a  development  of  the  symp- 
toms as  in  the  original  state.  Thomas 
Fraser  (Brit.  Med.  Jour.,  March  3, 
1906). 

The  danger  signals  when  thyroid  is 
used   in   myxedema   are,    as    in   cretin- 


ism :  tachycardia,  palpitations,  prostra- 
tion with  sweating,  rapid  emaciation, 
gastrointestinal  disorders,  anemia,  head- 
ache, and  in  some  cases  excitement 
recalling  hysteria.  When  the  doses 
(even  though  small)  are  too  large  for 
the  patient,  urticaria  may  appear.  This 
is  due  to  cutaneous  irritation  caused  by 
the  more  or  less  toxic  wastes  produced 


Fig.  3.— True  myxedema;  sister  of  patient 
in  Figs.  1  and  2.  {Hertoghe:  Bulletin  de 
I'Academie    Royale    de    Medecine    de   Belgique,) 

in  excess  owing  to  the  excessive  catab- 
olism  induced,  and  which  the  kidneys 
cannot  eliminate  with  sufficient  rapid- 
ity. Cessation  of  the  drug  for  a  few 
days  usually  causes  all  these  morbid 
effects  to  disappear,  after  which  the 
remedy  may  be  resumed  in  very  small 
doses. 

Case  illustrating  in  turn  excessive 
and  deficient  activity  of  the  thyroid 
in  a  child  of  10  years:  I.  Hyperthy- 
roidism, or  exophthalmic  goiter,  with 
the  classical  symptoms  of  (a)  exoph- 


126 


Animal  extracts  (SAJOuS). 


thalmos,  (&)  enlargement  of  the  thy- 
roid gland,  (c)  hyperexcitability,  (rf) 
a  moderately  rapid  pulse,  and  (<?)  loss 
of  weight.  II.  Hypothyroidism,  myx- 
edema, with  the  symptoms  of  (a) 
mental  and  physical  dullness,  (&) 
rapid  increase  of  adipose  tissue  in 
irregular  masses,  and  (c)  pallor.  III. 
Stage  of  balance,  a  disappearance 
of  the  myxedematous  characteristics 
even  though  the  weight  was  increas- 
ing. That  other  glands  besides  the 
thyroid  were  involved  was  probably 
true.  This  case  illustrated  the  fact 
that  many  minor  disturbances  of  the 
thyroid  gland  were  probably  unrecog- 
nized. S.  V.  Haas  (Med.  Record, 
Oct.  7,  1911). 

After  recovery,  the  patient's  health 
can  usually  be  maintained,  i.e.,  recur- 
rence of  the  disease  prevented,  by  ad- 
ministering small  doses,  1  grain  (0.065 
Gm.)  daily  or  every  other  day — just 
enough  to  sustain  the  temperature  up  to 
normal.  In  winter  it  is  sometimes  nec- 
essary to  increase  the  dose  somewhat 
to  obtain  this  result.  The  prolonged 
use  of  the  remedy  does  not,  with  rare 
exceptions,  diminish  the  need  of  it  to 
ward  off  the  disease;  cessation  after 
several  years'  use  will  be  followed  by 
prompt  recurrence  of  the  morbid  phe- 
nomena. 

Case  in  a  man  of  36  years  in  which, 
after  recovery  from  the  initial  treat- 
ment by  the  thyroid  extract  (which 
lasted  two  months  in  continuous  dos- 
age), the  patient  was  never  under  treat- 
ment longer  than  four  weeks  at  one 
time.  The  longest  respite  from  thyroid 
therapy  was  for  a  period  extending 
from  May,  1907,  to  October  of  the  same 
year,  a  period  of  five  months ;  at  the 
end  of  this  time  some  of  the  old  symp- 
toms were  again  in  evidence,  namely, 
characteristic  color,  loss  of  expression, 
swelling  and  puffiness  under  the  eyes ; 
the  mentality,  however,  continued  good. 
The  patient  himself  wanted  to  be  placed 
under  treatment  again.  An  interesting 
feature    of    the    case,    aside    from    its 


rarity  in  these  parts,  is  that  if  the  pa- 
tient takes  more  than  three  tablets  a 
day,  now  that  a  cure  is  established,  or 
continues  the  treatment  for  more  than 
three  weeks,  he  soon  shows  the  symp- 
toms of  exophthalmic  goiter,  namely, 
nervousness,  sleeplessness,  slight  ex- 
ophthalmos, nausea,  sometimes  vomit- 
ing and  general  weakness.  S.  E.  Sim- 
mons (Jour.  Amer.  Med.  Assoc,  May 
15,  1909). 

Occasionally  a  case  is  met  with  in 
which  the  thyroid  treatment  is  followed 
by  permanent  recovery.  Such  cases  are 
probably  instances  of  temporary  myxe- 
dema due  to  obstruction  of  the  lym- 
phatics through  which  the  secretion 
gains  access  to  the  general  circulation, 
or  to  some  other  factor  interfering 
temporarily  with  the  functions  of  the 
gland. 

Between  the  cases  in  which  contin- 
uous after-treatment  is  required  and 
those  that  proceed  to  recovery  are 
some  in  which  respites  of  several  weeks 
in  the  after-treatment  are  required  to 
obtain  the  best  results.  This  is  a  re- 
sult obtained,  however,  only  when  large 
doses  of  thyroid  are  used  in  the  after- 
treatment.  There  is  danger  in  such 
cases  of  causing  hyperthyroidism,  i.e., 
the  symptoms  of  exophthalmic  goiter, 
and  it  is  preferable  to  reduce  the  dose 
until  the  exact  quantity  required  con- 
tinuously to  keep  the  patient  well  is 
ascertained. 

Thyroid  grafting  has  been  performed 
successfully  in  animals,  especially  by 
Christiani,  and  more  recently  in  human 
subjects  suffering  from  myxedema  or 
cretinism.  In  the  earlier  operations, 
the  improvement  lasted  only  as  long  as 
the  secretion  that  happened  to  be  in 
the  implanted  tissues  lasted,  but  in  re- 
cent years  better  results  have  been  ob- 
tained, the  grafted  fragments  of  thy- 
roid   assuming  physiological    functions 


ANIMAL  EXTRACTS    (SAJOUS). 


727 


to  a  sufficient  degree  to  prevent  recur- 
rence of  the  disease. 

Case  of  a  young  woman  who,  becom- 
ing tired  of  the  preventive  treatment  by- 
thyroid,  requested  a  substitute.  The 
writers  inserted  portions  of  a  sheep's 
thyroid  gland  in  a  series  of  grafts  un- 
der her  skin  on  two  occasions  three  and 
a  half  months  apart.  The  thyroid  feed- 
ing was  gradually  diminished  until  it 
was  reduced  to  a  few  drops  a  day  of  a 
liquid  extract.  About  six  months  after 
•  the  second  transplantation  the  patient 
was  delivered  at  term  of  a  well-de- 
veloped healthy  infant.  It  was  ob- 
served that  during  the  latter  months  of 
her  pregnancy  the  grafts  became  en- 
larged, evidently  from  congestion,  being 
aflfected  like  the  normal  thyroid  by  the 
pregnancy.  The  successful  termination 
of  the  pregnancy  was  ascribed  in  great 
part  to  the  thyroid  treatment,  and  espe- 
cially the  implantation  of  the  function- 
ally active  thyroid  under  the  skin. 
Lannelongue,  in  a  case  of  a  myxedema- 
tous infant,  had  previously  implanted 
the  first  fragment  of  a  sheep's  thyroid 
in  the  human  subject.  The  child's  con- 
dition appeared  improved,  and  the  de- 
velopment of  the  disease  became  a  little 
less  active.  Charrin  and  Christian! 
(Le  Bull,  medicale,  July  11,  1906). 

The  writer  has  been  experimenting 
on  rabbits,  the  results  encouraging  fur- 
ther attempts  to  suppl}^  the  missing 
function  by  implantation  of  thyroid  tis- 
sue. The  best  results  can  certainly  be 
obtained  with  repeated  implantation  of 
small  scraps,  and  for  this  it  is  better  to 
implant  the  scraps  in  the  subcutaneous 
tissue  (Christiani)  or  in  the  peritoneal 
tissue  (von  Eiselsberg).  H.  Salzer 
(Wiener  klin.  Woch.,  March  18,  1909; 
Jour.  Amer.  Med.  Assoc,  April  24, 
1909). 

Series  of  personal  experiments  in 
thyroid  implantation  showed  that  thy- 
roid tissue  of  the  guinea-pig  trans- 
planted in  the  same  animal  heals  most 
easily  and  best  when  the  transplantation 
is  made  into  the  subcutaneous  connect- 
ive tissue ;  likewise,  the  peritoneal  cavity 
shows  itself  a  very  favorable  implanta- 
tion site ;  that  transplantations  into  the 


spleen  heal  fairly  well,  but  the  end 
results  are  less  good  and  not  so  certain 
as  those  obtained  when  one  uses  as 
implantation  sites  the  two  places  above 
named;  the  liver  and  the  bone-marrow 
are  very  unfavorable  organs  for  the 
healing  in  the  thyroid  tissue ;  that  thy- 
roid transplantation  promises  in  general 
more  fruitful  results  if  one  avoids  all 
bleeding  in  the  pocket  destined  to  re- 
ceive the  graft;  that  if  one  transplants 
the  thyroid  tissue  in  conjunction  with 
the  connective-tissue  capsule  pertaining 
to  it  it  is  to  be  observed  that  the  fol- 
licles in  the  vicinity  of  this  capsule  are 
better  preserved  and  more  numerous 
than  the  more  remote  follicles ;  that  the 
best  results  are  attained  if  one  trans- 
plants into  the  subcutaneous  tissue  very 
thin  slices  of  thyroid  tissue  instead  of 
larger  pieces;  one  condition  is  that  one 
of  the  surfaces  of  the  implanted  piece 
is  covered  by  the  connective-tissue  cap- 
sule of  the  thyroid.  Carraro  (Deut. 
Zeit.  f.  Chir.,  Feb.,  1909). 

Obesity. — The  treatment  of  this 
condition  by  means  of  thyroid  prep- 
arations was  far  more  in  vogue  a  few^ 
years  ago  than  at  present,  owning  mainly 
to  its  indiscriminate  use  by  laymen,  and 
to  the  use  of  excessive  doses  by  the 
profession.  Both  these  features  v^ere 
the  cause  of  dangerous  phenomena 
(and  sometimes  death)  during  the 
course  of  treatment,  or  of  pernicious 
after-effects.  When  thyroid  prepara- 
tions are  used  intelligently,  however, 
adjusting  the  dose  to  the  needs  of  each 
case,  and  regulating  judiciously  the 
concomitant  diet — ^which  in  some  cases 
means  an  increase — a  great  deal  of 
good  may  be  done  in  the  great  major- 
ity of  cases,  besides  improving  the  ap- 
pearance of  the  patient  and  his  general 
well-being. 

The  cases  in  which  thyroid  prepara- 
tions act  favorably  are  those  in  which 
metabolic  activity,  especially  its  cata- 
bolic  phase,  is  deficient.  The  fat,  ruddy 
boy  or  the  plethoric,  vigorous,   red- 


728 


ANIMAL  EXTRACTS    (SAJOUS). 


faced  high-liver  do  not  belong  to  this 
category.  Those  that  do  are  pale, 
flabby,  anemic,  in  most  instances  fe- 
males between  25  and  45  in  which  the 
heart  beat  is  weak,  sometimes  irregulai 
and  rapid  with  compressible  pulse 
The  fat  in  such  is  more  or  less  irreg- 
ularly distributed  in  the  subcutaneous 
tissues;  they  suffer  from  dyspnea,  es- 
pecially on  exertion,  and  fall  asleep 
readily  at  any  time.  Such  cases  are  in 
reality  instances  of  mild  myxedema  in 
which  the  thyroid  does  not  supply  quite 
enough  secretion  to  satisfy  the  needs 
of  the  organism.  It  is  not  a  question 
of  overeating  with  them ;  such  patients, 
in  fact,  are,  as  a  rule,  abstemious,  the 
slowness  of  their  tissue  exchanges 
causing  them  to  have  but  little  appetite. 
Unable  to  burn  up  their  carbohydrates, 
sugars,  starches,  and  fats  as  fast  as 
they  are  ingested,  fat  steadily  accumu- 
lates in  all  tissues. 

Thyroid  preparations,  when  judi- 
ciously used  under  such  circumstances, 
are  of  value  mainly  because  the  role  of 
thyroid  secretion  they  replace  is  pre- 
cisely— from  my  viewpoint — to  en- 
hance the  catabolic  phase  of  metab- 
olism, essentially  the  function  at  fault 
in  obesity.  The  fat-cell  is  rendered 
more  susceptible  to  oxidation — along 
with  the  other  tissues — and  the  excess 
of  fat  is  steadily  consumed. 

Series  of  about  100  cases  of  obesity 
in  which  thyroid  extract  was  used.  No 
untoward  symptoms  were  noticed  in  any 
of  the  cases,  malaise,  headache,  palpita- 
tion, and  nervous  derangement  being 
entirely  absent.  Albuminuria  was  not 
seen  at  any  time.  The  thyroid  gland 
used  in  all  instances  was  B.  W.  &  Co. 
tabloids.  The  initial  dose  was  lYi 
grains  with  each  meal,  either  mixed 
with  the  food  or  taken  with  a  little 
water.  After  seven  days  the  dose  was 
increased  to  5  grains  with  each  meal, 
and  this  dose  was  not  increased  in  any 


case.  The  tabloids  were  crushed  before 
being  taken.  In  the  successful  cases 
summarized  below  no  alteration  in  diet 
was  ordered,  the  patient  eating  and 
drinking  anything  he  or  she  desired. 
Alcohol  was,  however,  strictly  pro- 
hibited in  any  form. 

Of  78  females  treated  69  were  be- 
tween 25  and  45 ;  their  average  weekly 
loss  was  2J^  to  4  pounds,  and  the  re- 
sult was  permanent  cure ;  9  were  be- 
tween 15  and  19,  and  there  was  no 
permanent  result  in  any  of  them.  Of 
25  men  9  were  between  30  and  47;  they 
lost  on  an  average  2  to  3^  pounds 
weekly;  the  cure  was  permanent;  11 
men  between  30  and  47  lost  1  to  1^ 
pounds  on  an  average,  but  the  result 
was  not  permanent;  on  5,  between  14 
and  17,  there  was  no  eflfect  at  all. 
W.  J.  Hoyten  (Brit.  Med.  Jour.,  July 
28,  1906). 

In  the  treatment  of  constitutional 
obesity  the  writer  uses  Merck's  thy- 
roid-gland tablets  containing  0.1  gram 
of  gland.  One  to  2  tablets  are  given 
daily  during  the  first  three  to  four 
days,  and  during  the  following  eight 
to  ten  days  the  dose  is  increased  to  3 
tablets;  in  very  exceptional  cases  as 
many  as  4  tablets  may  be  given.  The 
dose  is  now  decreased  to  2  tablets  for 
the  following  eight  days,  and  then  to 
1  tablet  for  another  five  to  eight  days, 
after  which  a  pause  of  eight  days  is 
allowed  before  recommencing  the 
treatment  on  the  same  lines.  This 
pause  must  be  made,  as  in  every  case 
after-effects  occur,  lasting  some  time. 
After  two  or  three  courses  of  treat- 
ment a  longer  pause,  extending  to 
about  three  months,  may  be  made;  its 
duration  depends  upon  the  patient's 
weight,  which  should  be  frequently 
ascertained.  C.  Pariser  (Zeit.  f. 
Aerztl.   Fortbildung,  Nu.  5,  1911). 

Contraindications  to  the  use  of  thy- 
roid preparations  in  obesity  have  been 
elaborated  by  various  observers;  but 
perusal  of  their  work  indicates  clearly 
that  they  have  been  administering  ex- 
cessive doses.  Such  doses  are  always 
dangerous  in  the  obese,  since  the  heart 


ANIMAL   EXTRACTS    (SAJOUS). 


729 


is  itself  invariably  fatty,  while,  con- 
versely, small  doses  are  always  helpful 
because  they  very  gradually  rid  the 
heart  of  the  fat  which  compromises  its 
functions  and  eventually  causes  death 
when  the  patient  has  not  been  carried 
off  by  some  intercurrent  disorder. 
Even  moderate  doses  have  not  proven 
harmful  when  the  patient  was  under 
medical  surveillance. 

The  dose  of  desiccated  thyroid  need 
not  exceed  1  grain  (0.65  Gm.)  three 
times  daily  in  any  case.  This  suffices 
to  cause  a  decrease  of  weight  of  from 
one  to  three  pounds  a  week,  and  some- 
times more,  Anders  ("Practice,"  8th 
ed.,  p.  1276)  having  observed  in  2 
cases  under  this  dose  "a  progressive 
loss  of  weight  at  the  rate  of  4  to  6 
pounds  per  week,  respectively,  without 
injury  to  the  general  health."  Such 
doses  do  not  impose  upon  the  patient 
the  need  of  modifying  his  usual  mode 
of  living,  and  his  diet  need  not,  unless 
excessive,  be  altered.  When  the  obesity 
is  accompanied  by  weakness,  the  appe- 
tite is  usually  increased,  especially 
when,  as  is  my  custom,  gr.  %o  (0.0012 
Gm.)  of  strychnine  is  given  with  each 
dose  of  desiccated  thyroid.  The  pa- 
tient does  best  under  these  conditions 
when  lean  meats,  plainly  broiled, 
roasted,  or  stewed,  constitute  the  in- 
crease of  his  dietary.  This  treatment 
is  valuable  in  another  direction:  it 
tends  to  counteract  any  tendency  to 
constipation  that  may  be  present. 

Danger  signals  or  untozvard  effects 
are  not  met  with  when  small  doses  are 
given,  as  previously  stated,  but  the 
physician  has  occasionally  to  treat  some 
victim  of  excessive  dosage. 

Case  in  which  a  man  took  for 
obesity  nearly  1000  S-grain  tablets  of 
thyroid  extract  within  five  weeks. 
After  the  first  three  weeks  he  began 


rapidly  to  develop  the  symptoms  of 
acute  Graves's  disease.  When  thy- 
roid was  stopped  and  patient  was  put 
upon  arsenic  all  the  symptoms  dis- 
appeared quickly,  excepting  the  eye 
changes  and  the  goiter,  which  were 
still  notable  for  about  six  months. 
A.  V.  Notthaft  (Centralbl.  f.  innere 
Med.,  April  16,  1898). 

The  untoward  effects  most  fre- 
quently met  with  in  obese  subjects  are 
of  cardiac  origin :  marked  discomfort 
in  the  precordia,  dyspnea  with  tend- 
ency to  heart-failure.  In  some  in- 
stances this  has  been  followed  by  death 
when  marked  fatty  degeneration  hap- 
pened to  be  present.  But,  as  stated, 
these  do  not  occur  when  small  doses — 
1  grain  (0.065  Gm.)  of  the  desiccated 
thyroid — are  used.  Even  the  greatest 
watchfulness  will  not  prevent  toxic  ef- 
fects when  large  doses  are  adminis- 
tered, since  the  accumulation  of  the 
thyroid  principle  proceeds  at  a  rapid 
rate  and  the  milder  symptoms  of  thy- 
roidism  are  almost  at  once  followed 
by  its  acute  manifestations — those  pre- 
viously described. 

Miscellaneous  Disorders. — In  the 
foregoing  diseases  thyroid  treatment 
may  be  regarded  as  a  specific,  none 
other  affording  satisfactory  results.  Its 
use  is  being  extolled  in  many  other  dis- 
orders ;  but  it  is  still  a  question  whether 
it  procures  better  effects  or  even  as 
good  results  as  other  available  rem- 
edies. These  will  be  considered  in 
their  alphabetical  order. 

Acroniegaly. — The  reports  of  cases 
of  this  disease  treated  with  thyroid 
have  been  insufficient  to  warrant  a  con- 
clusion, the  results  having  been  contra- 
dictory. This  is  probably  due  to  their 
empirical  use.  According  to  my  inter- 
pretation of  the  disease :  hypertrophy 
of  the  pituitary  causes  excessive  activ- 
ity of  the  adrenals  and  thyroid  (which 


730 


ANIMAL   EXTRACTS    (SAJOUS). 


the  pituitary  governs)  for  a  time,  i.e., 
during  the  sthenic  period  of  the  disease. 
Given  during  this  period,  thyroid  prep- 
arations can  only,  therefore,  add  fuel 
to  the  fire  and  do  harm.  There  comes 
a  time,  however,  usually  after  several 
yea;"s,  when  the  enlargement  of  the  pit- 
uitary ceases  and  degeneration  of  this 
organ  occurs,  initiating  the  asthenic 
period.  The  adrenals  and  thyroid 
then  usually  reduce  their  functional  ac- 
tivity inordinately,   and   oxidation  and 


Case  illustrating  the  association  of  acromegaly 
and  goiter.    (6.  B.  Murray.) 

metabolism  are  inadequate  for  the  per- 
petuation of  the  vital  functions.  Here 
thyroid  (preferably  with  adrenal)  is 
useful  and  may  serve  greatly  to  pro- 
long life. 

Case  of  acromegaly  treated  with 
dried  thyroid  extract  in  gradually  in- 
creasing doses  until  12  grains  a  day 
were  taken,  besides  galvanism  and 
tonics.  Three  months  later  she  was 
feeling  very  much  better,  her  memory 
had  improved,  and  she  spoke  and 
moved  more  rapidly.  She  had  lost 
over  20  pounds  in  weight,  but  felt 
stronger.  General  condition  prac- 
tically the  same.  The  history  .  of 
-the  case  and  the  marked  physical 
changes  leave  little  doubt  that  it  was  a 
case  of  acromegaly,  but  certain  anom- 


alous symptoms — such  as  the  pufify  con- 
ditions of  the  eyelids,  which  may,  how- 
ever, have  been  simply  the  result  of 
anemia,  though  its  appearance  was 
somewhat  different;  the  slow  speech, 
and  the  altered  mental  state — suggested 
that  her  condition  was  also  associated 
with  a  loss  of  function  of  the  thyroid 
gland.  G.  G.  Sears  (Boston  Med.  and 
Surg.  Jour.,  July  2,  1896). 

Case  of  a  woman  26  years  old  who 
had  suffered  from  acromegaly  for  up- 
ward of  two  years,  and  who  for  a 
period  of  five  months  had  been  treated 
with  mixed  pituitary  and  thyroid  ex- 
tracts, with  great  improvement.  The 
superficial  resemblance  between  acro- 
megaly and  myxedema  seemed  to  justify 
the  administration  of  thyroid  extract, 
especially  as  in  several  cases  of  acro- 
megaly treatment  with  pituitary  extract 
alone  had  failed  to  effect  any  improve- 
ment. Rolleston  (Brit.  Med.  Jour., 
April  17,  1897). 

Arteriosclerosis. — As  is  well  known, 
the  iodides  are  used  with  benefit  in 
this  condition.  It  naturally  follows 
that  thyroid  preparations,  which  owe 
their  therapeutic  activity  to  the  iodine 
in  organic  combination  they  contain, 
should  likewise  prove  beneficial.  This 
proved  true  in  cases  reported  by  Lan- 
cereaux  (La  Semaine  med.,  Jan.  4, 
1899),  James  Barr  (Brit.  Med.  Jour., 
Jan.  20,  1906),  and  other  authorities. 
The  favorable  action  of  thyroid  in 
these  cases,  however,  necessitates  the 
use  of  large  doses — 5  grains  (0.3  Gm.) 
three  times  a  day — enough  to  cause 
general  vasodilation.  As  such  doses  are 
unsafe  in  aged  subjects,  who  constitute 
the  greatest  proportion  of  our  cases, 
its  use  should  be  limited  to  middle-aged 
patients,  therefore,  reserving  the  io- 
dides for  the  former.  Sir  James  Barr, 
in  fact,  considers  iodine  more  valuable 
than  thyroid  preparations. 

Arthritis,  Chronic  Rheumatoid. — 
In  this  disease  sfood  results  are  occa- 


ANIMAL  EXTRACTS    (SAJOUS). 


731 


sionally  obtained  when  no  other  agent 
will  produce  the  least  effect.  Leopold- 
Levi  and  de  Rothschild,  for  example, 
describe  the  phenoniiena  observed  in 
2  cases  of  chronic  rheumatism  with 
hydrarthrosis  in  which  thyroid  extract 
proved  of  distinct  value.  In  1  of 
these  the  hydrarthrosis  followed  a  fall 
from  a  bicycle,  and  was  the  precursor 
of  attacks  of  muscular  rheumatism,  all 
the  joints  being  gradually  involved  in 
the  morbid  process.  Notwithstanding 
seasons  at  Aix-les-Bains,  Dax,  and 
other  stations,  the  patient  became  quite 
impotent,  having  even  to  be  fed.  The 
usual  remedies  proved  unavailing, 
though  aspirin  and  iodine  seemed,  at 
least  for  a  while,  to  be  of  some  benefit. 
The  patient's  condition  becoming  stead- 
ily worse,  thyroid  extract  was  tried,  be- 
ginning with  1^4  gi'ains  every  other 
day  during  ten  days,  followed,  after 
five  days,  by  resumption  of  the  rem- 
edy; then  giving  again  only  1%  grains 
every  other  day.  This  dose  was  grad- 
ually increased  until,  eleven  months 
later,  the  patient  was  taking  7^  grains, 
in  divided  doses,  daily.  Good  results 
have  also  been  recorded  by  Revilliod, 
Lancereaux,  and  others. 

The  beneficial  effects  of  the  drug  be- 
come self-evident  when  its  action  and 
the  pathogenesis  of  chronic  rheumatism 
are  interpreted  from,  my  standpoint. 
Briefly,  while  I  have  ascribed  this  dis- 
ease to  "inadequate  catabolism  of  tissue 
wastes,  and  excitation,  by  the  toxic 
products  formed,  of  the  vasomotor 
center"  thyroid  extract,  as  stated  in  the 
foregoing  pages,  enhances  general  oxi- 
dation and  the  destruction  of  wastes, 
by  increasing  the  blood's  asset  in  op- 
sonin and  autoantitoxin. 

Thus,  increase  of  appetite  was  the 
first  effect  noted  in  the  cases  referred 
to  above ;  this  is  a  normal  result,  since 


the  greater  cellular  activity  and  catab- 
olism created  a  greater  demand  for 
■  foodstuffs.  Increased  heat  production 
soon  replaced  the  marked  and  constant 
chilliness  from  which  the  patient  suf- 
fered— an  effect  due  to  the  marked  in- 
crease of  oxidation  the  thyroid  extract 
engendered  throughout  the  body.  The 
dose  was  increased  to  1^  grains  one 
day,  then  to  3  grains  the  next,  this  being 
continued  ten  days.  After  a  period  of 
rest  of  five  days,  3  grains  were  again 
given  daily.  The  pain  became  less — a 
fact  due  to  decrease  of  the  vascular  ten- 
sion, owing  to  increased  destruction  of 
the  toxic  wastes  which,  as  I  have 
pointed  out  elsewhere,  excite  the  vaso- 
motor center,  thus  causing  constriction 
of  all  arteries.  The  sensory  nerve-ter- 
minals being  relieved  of  the  hyperemia 
which  caused  the  pain,  the  latter  be- 
came less  marked  in  proportion. 
Closely  connected  with  this  beneficial 
action  was  the  effect  on  the  joints,  viz. : 
the  hydrarthrosis  became  reduced.  Be- 
ing also  due  to  excessive  vascular  ten- 
sion, it  is  plain  that  by  causing  vaso- 
dilation, in  the  manner  just  explained, 
thyroid  extract  caused  the  excess  of 
fluid  to  leave  the  joints.  The  dose  be- 
ing still  further  increased  until  7^4 
grains  were  taken  daily,  emaciation 
occurred — a  well-known  effect  due  to 
excessive  catabolism  provoked  by  large 
doses  of  thyroid  extract. 

Eleven  months'  treatment  brought 
Leopold-Levi  and  de  Rothschild's  case 
back  to  a  condition  of  comfort,  the 
joints  having  resumed  their  shape  and 
flexibility — with  the  exception  of  one 
knee,  which  remained  ankylosed — ow- 
ing doubtless  to  fibrosis,  a  condition 
beyond  the  reach  of  the  remedy.  This 
does  not  militate  against  its  use,  how- 
ever; it  simply  shows  that  the  treat- 
ment was  resorted  to  too  late  to  avoid 


732 


ANIMAL   EXTRACTS    (SAJOUS). 


irremediable  organic  lesions.  The  au- 
thors, in  fact,  refer  to  a  case  treated 
by  Parhon  and  Papinian  (Presse  med.,  • 
No.  1,  p.  3,  1905)  in  which  thyroid 
extract  had  produced,  though  the  dis- 
ease was  of  twenty-four  years'  stand- 
ing, "a  true  regeneration."  When  7% 
grains  (in  five  divided  doses)  daily  had 
been  given  some  time,  palpitations, 
tachycardia,  and  arrhythmia  appeared. 
On  withdrawing  the  remedy  these  un- 
toward effects  ceased,  but  recurred  as 
soon  as  its  use  was  resumed.  This 
affords  additional  evidence  in  support 
of  a  fact  I  have  often  emphasized,  viz. : 
that  the  beneficial  effects  of  thyroid 
extract  are  obtained  only  when  small 
doses  are  used. 

Case  of  rheumatoid  arthritis  in 
which  most  of  the  ordinary  methods 
of  treatment  for  the  condition  were 
tried  without  any  beneficial  result. 
Finding  on  examination  that  her  thy- 
roid was  small,  the  writer  commenced 
giving  thyroid  extract,  2  grains  three 
times  a  day,  and  after  a  week  four 
times  a  day.  In  about  two  months 
all  the  pain  and  nearly  all  the  swell- 
ing had  gone  from  both  knees;  there 
was  no  fluid  in  the  left  knee  and 
hardly  any  in  the  right  knee.  A  week 
later  there  was  no  fluid  in  the  right 
knee,  and  in  a  few  days  more  all  the 
swelling  had  disappeared.  G.  Steele- 
Perkins  (Lancet,  March  5,  1910). 

Case  of  rheumatoid  arthritis  in 
which  the  writer  was  struck  by  the  pa- 
tient's rough,  dry,  harsh  skin,  crisp  hair, 
husky  voice,  and  deep  suprasternal 
notch;  the  prominence  of  the  trachea, 
and  apparent  absence  of  thyroid  gland, 
analogy  to  other  conditions  suggesting 
deficiency  of  thyroid  secretion. 

Accordingly,  the  extract  of  thyroid 
was  administered  in  doses  of  5  grains 
three  times  daily,  together  with  adju- 
vant treatment  to  be  mentioned  pres- 
ently. In  a  month  the  results  were  re- 
markable. The  patient  could  struggle 
on  crutches  from  one  room  to  another, 
his  appetite  returned,  and  pain  was  al- 


most gone.  In  three  months  he  could 
walk  with  two  sticks,  and  in  eighteen 
months  he  was  able  to  walk  three  miles 
with  the  aid  of  one  stick.  His  elbows 
and  shoulders  have  regained  their 
mobility  almost  entirely,  and  he  has 
been  for  a  year  able  to  do  without  his 
thyroid  extract  without  a  relapse.  At 
the  present  date  he  is  able  to  get  about 
well,  with  slight  flexion  of  one  knee 
and  some  metacarpophalangeal  deform- 
ity, but  is  fat  and  well. 

Two  additional  cases  in  which  marked 
improvement  occurred.  In  the  writer's 
opinion  the  group  of  cases  likely  to 
receive  benefit  are  those  in  which 
changes  are  chiefly  confined  to  the  sy- 
novial membranes,  without  erosion  of 
cartilage  or  eburnation  of  bone,  such 
cases  in  fact  as  Schiiller  describes  as 
"chronic  villous  arthritis."  Wilson 
(Brit.  Med.  Jour.,  Dec.  10,  1910). 

Cancer.— Thy  roid  preparations  have 
been  tried  by  a  number  of  clinicians 
in  this  disease.  Some  have  obtained 
favorable  results;  others  observed  only 
temporary  benefit;  others  again  have 
observed  no  effect  whatever. 

In  the  first  place,  thyroid  prepara- 
tions should  be  used  only  in  absolutely 
inoperable  cases,  surgery  having  given 
far  better  results  than  any  odier 
method,  including  X-rays  and  thyroid 
preparations.  In  the  second  place,  it 
is  a  mistake  to  attribute  specific  or 
even  curative  properties  to  thyroid 
preparations  alone.  They  only  assist  in 
the  curative  process  by  facilitating  pro- 
teolysis, i.e.,  breaking  down  of  the 
growth.  The  detritus  is  such  that  after 
its  use  the  kidneys  are  greatly  exposed, 
and  cases  have  been  reported  in  which 
fatal  nephritis  followed  the  use  of 
large  doses.  Such  doses  are,  therefore, 
dangerous.  Small  doses  do  quite  as 
well ;  but  even  when  these  are  used 
the  patient  should  be  ordered  to  drink 
at  least  one  quart  of  water  daily,  pref- 
erably   a    mineral    water,    to    promote 


ANIMAL   EXTRACTS    (SAJOUS). 


733 


flushing  of  the  kidney  and  thus  facil- 
itate the  ehmination  of  toxic  wastes 
and  detritus.  One  or  2  grains  of  desic- 
cated tliyroid  three  times  daily  usually 
suffice,  but  3  grains  can  be  given  if  no 
rise  of  temperature  is  observed. 

Case  of  multiple  carcinoma  of  the 
skin  and  subcutaneous  tissue  in  a 
widow  aged  61.  The  original  growth 
had  been  removed  a  year  before  the 
author    saw    the    patient,    but    other 

•  growths  had  since  appeared,  and  the 
patient's  health  was  declining.  Thy- 
roid medication  was  tried,  starting 
with  5  grains  daily,  gradually  in 
creasing  to  10  grains,  and  finally  to 
IS  grains,  daily.  The  patient  quickly 
showed  signs  of  improvement;  the 
palpitation,  sickness,  and  emaciation 
gradually  disappeared  pari  passu  with 
the  gradual  disappearance  of  the 
growths.  In  less  than  three  months 
the  growths  had  entirely  disappeared, 
the  patient  was  practically  well,  and 
had  recovered  her  lost  weight  of  3 
stone.  This  occurred  in  1901,  and  at 
present  the  patient  is  still  well  and 
has    not    suffered    since.     The   writer 

■  summarizes  other  and  similar  cases 
from  medical  literature.  E.  Hughes 
Jones  (Brit.  Med.  Jour.,  Feb.  25, 
1911). 

Case  of  cancer  of  the  larynx.  The 
patient  was  a  man  51  years  of  age  who 
developed  malignant  disease  of  the 
larynx  for  which  total  extirpation  of 
the  larynx  was  done.  After  an  attack 
of  secondary  hemorrhage  the  patient 
finally  began  to  recover  on  the  sixteenth 
day  after  the  operation  and  gradual 
healing  occurred.  About  three  months 
later,  a  mass  of  glands  over  the  right 
carotid  sheath  were  found  to  be  second- 
arily affected,  and  these  were  removed. 
He  kept  well  for  eight  or  nine  months 
after  this  operation,  and  then  recurrence 
of  the  growth  took  place  and  a  lump  as 
large  as  a  walnut  developed  on  the  right 
side  of  the  neck.  An  attempt  was  made 
to  remove  it,  but  it  was  found  at  the 
operation  that  the  growth  involved  not 
only  the  common  carotid  artery,  but  the 
prevertebral     muscles.       Complete     re- 


moval could  be  accompHshed  only  by 
exposing  a  healthy  portion  of  the  com- 
mon carotid,  ligating  it,  and  dissecting 
the  cancerous  mass  up  from  below  and 
sacrificing  the  pneumogastric  nerve,  an 
operation  that  would  almost  certainly 
have  been  fatal,  while  it  gave  little  or 
no  prospect  of  eradicating  the  disease. 
The  lower  portion  of  the  mass  involved 
the  thyroid  gland.  Accordingly,  the 
operation  was  abandoned  except  that  a 
small  portion  was  removed  for  micro- 
scopic examination.  This  proved  to  be 
cancerous.  A  few  days  later,  the  pa- 
tient was  seen  on  consultation  with  Sir 
Charles  Ball,  who  suggested  that  thj'- 
roid  extract  should  be  given  and  cited 
2  cases  of  inoperable  cancerous  lym- 
phatic glands  in  which  that  remedy  had 
been  tried  with  success.  Three-grain 
doses  of  the  extract  were  prescribed 
three  times  daily.  At  the  end  of  four 
months'  treatment,  there  was  distinct 
diminution  in  size  of  the  glands.  The 
thyroid  extract  was  continued  with  the 
result  that  the  growth  finally  disap- 
peared completely,  and  the  patient  be- 
came quite  well. 

There  is  now  a  series  of  well-authen- 
ticated cases  of  cancerous  recurrences 
on  lymphatic  glands  cured  by  thyroid 
extract.  R.  H.  Woods  (London  Letter, 
N.  Y.  Med.  Jour.,  July  22,  1911). 

The  other  agents  indicated  as  such 
as  would  be  warranted  were  the  same 
general  symptoms  met  in  other  disor- 
ders. The  anemia,  which,  with  the  gen- 
eral vasodilation  and  the  resulting  re- 
cession of  blood  from  the  surface, 
gives  the  patient  the  waxy  pallor  some- 
times observed,  should  be  met  by  iron, 
preferably  Blaud's  pill,  and  strychnine 
in  full  doses.  In  personal  cases,  by 
treatment  based  on  general  principles, 
using  thyroid  only  when  the  growths 
seemed  to  take  a  fresh  start,  they  have 
been  ke^t  in  abeyance  several  years, 
six  years  in  one  case,  four  years  in 
another. 

The  same  treatment  is  indicated  in 
cases  after  operation  to  prevent  recur- 


734 


ANIMAL   EXTRACTS    (SAJOUS). 


rence,  the  aim  here  being  to  enhance 
the  functional  activity  of  all  organs,  in- 
cluding those  which  govern  the  im- 
munizing processes.  General  tonics, 
especially  iron  and  strychnine,  and  out- 
of-door  life  are  of  especial  value  in 
this  connection. 

Cutaneous  Disorders. — After  a  pro- 
longed trial  of  thyroid  preparation  in 
many  diseases  of  the  skin,  dermatol- 
ogists have  come  to  the  conclusion 
that  they  were  indicated  .in  disorders 
due  to  deficient  metabolism.  As  re- 
cently stated  by  Winfield,  these  in- 
clude the  erythematobulbous  type, 
which  includes  dermatitis  herpetifor- 
mis, and  the  psoroeczematous  type,  to 
which  belong  prurigo,  psoriasis,  and 
chronic  eczema. 

This  is  fully  accounted  for  by  the 
action  of  thyroid  products  on  oxidation 
and  metabolism  I  have  described. 
This  is  well  shown  in  the  effects  noted 
by  Don:  1.  Increased  nutrition  of  the 
skin ;  hence  its  probable  remedial  action 
in  ichthyotic  conditions:  an  effect  pro- 
duced without  any  necessary  abnormal 
perspiration.  2.  Increased  action  of  the 
cutaneous  glands,  accelerating  excre- 
tion of  waste  products,  thus  keeping 
the  surface  in  a  supple  condition.  3. 
Regrowth  of  hair,  as  shown  in  myx- 
edema and  some  cases  of  general  alo- 
pecia. 4.  Increased  activity  of  the  epi- 
dermal layers,  causing  desquamation 
of  unhealthy  epidermis  and  reproduc- 
tion of  a  new  covering,  as  observed  in 
ichthyosis,  psoriasis,  dry  chronic  ec- 
zema, and  also  in  some  cases  of  myx- 
edema and  cretinism. 

Series  of  consecutive  caseo  of 
eczema  in  young  children  successfully 
treated  by  thyroid.  In  the  first  case, 
14  months  old,  the  baby  had  suffered 
from  eczema  of  the  face  for  nearly 
a  year.  This  had  been  entirely  re- 
sistant to  the  usual  applications  and 


internal  treatment,  nor  was  hospital 
treatment  more  efficacious.  Two  and 
a  half  grains  of  a  thyroid  tablet  were 
given  daily.  In  a  little  more  than  one 
month  the  child  was  entirely  well. 
His  cure  persisted  for  nearly  a  month, 
when  the  disease  showed  a  tendency 
to  recur.  The  second  course  of  thy- 
roid was  followed  by  a  permanent 
cure.  The  4  other  cases  gave  similar 
results.  Eason  (Scottish  Med.  and 
Surg.  Jour.,  May,  1908). 

Two  cases  of  eczematous  seborrhea 
successfully  treated  with  thyroid.  In 
the  first  case  the  scalp  was  normal  at 
the  end  of  two  weeks;  in  the  second 
in  one  month.  Complete  cure  occurred 
in  both  cases,  and  has  persisted.  Mous- 
sous  (Archives  de  med.  des  enfants, 
March,  1908). 

It  is  pretty  certainly  established  that 
preparations  from  certain  ductless 
glands  exert  a  marked  influence  upon 
those  dermatoses. due  to  faulty  metab- 
olism. There  is  a  certain  class  of  skin 
diseases,  those  belonging  to  the  ery- 
thematobullous  type  and  those  of  the 
psoroeczematous  variety,  in  which  the 
preparations  coming  under  the  head  of 
animal  therapy  seem  to  do  the  most 
good.  J.  M.  Winfield  (Interstate  Med. 
Jour.,  Nov.,  1909). 

In  psoriasis  thyroid  is  harmful 
when  the  eruption  is  developing,  but 
it  sometimes  acts  with  surprising  effi- 
cacy in  fully  developed  cases.  The  un- 
toward effects  observed  by  dermatolo- 
gists, however,  are  in  great  part  due 
to  the  fact  that  they  use  too  large  doses. 
These,  as  previously  stated,  .  enhance 
catabolism  violently  and  increase  the 
waste  products  in  the  blood  and,  there- 
fore, the  cutaneous  disorder. 

Five  cases  of  scleroderma  in  4  of 
which  the  thyroid  was  small  and  at- 
rophied, while  in  the  other  the  thyroid 
was  large  and  hard.  Thyroid  treatment 
gave  good  results  in  the  2  in  which  it 
was  applied,  commencing  with  small 
and  progressive  doses.  None  of  the 
patients  presented  signs  of  nervous 
changes  suggesting  atrophic  origin,  but 


ANIMAL   EXTRACTS    (SAJOUS). 


735 


everything  confirmed  the  assumption  of 
some  connection  between  the  cutaneous 
affection  and  the  thyroid  gland.  Ped- 
razzini  (Gaz.  degli  Ospedali,  Aug.  1, 
1909). 

Thyroid  has  been  tried  in  lupus  by 
a  number  of  observers.  Though  the 
results  were  contradictory,  the  bulk 
of  the  evidence  indicates  that  it  is 
worthy  of  further  trial.  Owing  to  its 
influence  orti  oxidation,  thyroid  en- 
hances the  nutrition  of  the  skin  and 
thus  antagonizes  the  destructive  proc- 
ess while  promoting  that  of  repair.  As 
full- doses  have  to  be  used  during  a 
prolonged  period,  the  patient  should 
be  carefully  watched.  Thyroid  has 
been  tried  in  leprosy,  but  the  results 
were  not  encouraging,  though  the 
remedy  was  pushed  as  far  as  safety 
would  allow. 

In  a  case  of  hypertrophic  rosacea 
which  has  resisted  all  forms  of  treat- 
ment, Isadore  Dyer,  of  New  Orleans, 
used  thyroid  with,  for  local  use,  a  salve 
containing  resorcin,  9  j ;  rose  water, 
5iv;  lanolin,  q.  s.  ad  qy'].  After  two 
months  there  was  decided  improvement, 
the  skin  being  soft  and  normal  to  the 
touch  and  the  color  greatly  improved. 
The  patient  was  discharged  cured  after 
three  months  of  thyroid  medication. 

Case  in  which  thyroid  treatment  was 
commenced  at  the  age  of  5  months ; 
in  two  months  the  congenital  ichthy- 
osis subsided,  and  in  two  months 
later  it  had  entirely  disappeared. 
After  suspending  the  thyroid  treat- 
ment, a  preparation  of  arsenic  was 
given.  The  ichthyosis  returned,  but 
yielded  ag,ain  to  the  resumption  of 
the  thyroid  treatment.  In  another 
child,  in  which  there  were  also  signs 
of  myxedema,  very  favorable  results 
were  obtained  from  the  thyroid  treat- 
ment. Certain  cases  of  ichthyosis 
ascribed  to  inherited  syphilis  are  really 
of  thyroid  origin,  the  thyroid  lesion 
being    possibly     secondary    to    syphilis. 


Weill    and    Mouriquand    (Presse    med., 
I'cb.  17,  1909). 

Case  of  elephantiasis  of  ten  years' 
duration  in  which  genuine  reduction  in 
size  of  epithelial  overgrowth  followed 
each  attempt  at  thyroid  administration, 
but  intervals  of  arsenical  treatment 
seemed  necessary  to  correct  the  severe 
constitutional  results  of  the  animal  ex- 
tract. Within  seven  months  the  pa- 
tient lost  11  kg.  of  body  weight  and 
the  feet  were  markedly  reduced,  the 
right  nearly  twice  as  much  as  the  left 
one.  The  patient  suffered  two  illnesses 
of  the  respiratory  tract  during  thyroid 
administration,  an  attack  of  pleurisy 
and  an  attack  of  pleuropneumonia  about 
five  months  later.  The  observer  sug- 
gests thyroid  treatment  for  other  der- 
mal morbid  processes  of  a  hypertrophic 
character.  F.  M.  Baca  (El  Observador 
Medico,  vol.  v,  No.  4,  p.  48,  1909). 

Exophthalmic  Goiter. — The  results 
of  treatment  by  thyroid  preparations 
have  been  variable.  In  one  case,  thy- 
roid will  produce  marked  benefit ;  in 
an  apparently  similar  case,  it  will  do 
considerable  harm.  In  truth,  there  are 
distinct  stages  of  the  disease,  which  be- 
come evident  in  the  light  of  the  role 
I  have  ascribed  to  the  thyroid,  viz. : 
that  of  increasing  the  vulnerability  of 
all  phosphorus-laden  cells,  including 
Avaste  products,  to  oxidation,  and  facil- 
itating (as  opsonin)  their  destruction  by 
the  defensive  constituents  of  the  blood, 
including  its  phagocytes. 

With  this  function  before  us,  what 
can  we  expect  from  thyroid  prepara- 
tions in  a  case  of  exophthalmic  goiter 
in  which  the  excretion  of  phosphoric 
acid  is  excessive  (sometimes  ten  times 
the  normal,  according  to  Scholtz)  and 
other  evidences  of  excessive  oxidation 
are  present?  Obviously  none.  Here 
a  toxemia  prevails,  probably  of  intes- 
tinal origin,  in  which  the  toxics  excite 
the  adrenothyroid  center.  The  thyroid 
and  its  mates,  the  adrenals,  being  stim- 


736 


ANIMAL   EXTRACTS    (SAJOUS). 


ulated  abnormally  to  increase  the  anti- 
toxic power  of  the  blood,  the  thyroid 
becomes  enlarged,  and  the  excess  of 
secretion  (added  to  a  corresponding 
excess  of  adrenal  secretion)  produces 
the  general  symptoms  of  the  disease. 
It  is  obvious  that  in  these  cases  thyroid 
preparations  can  only  do  harm,  and 
that  the  arrest  and  prevention  of  intes- 
tinal autointoxication,  by  suitable  aperi- 
ents and  a  proper  semimilk  diet  and 
physical  rest  to  reduce  muscular  wastes 
to  a  minimum,  are  indicated. 

There  comes  a  time,  however,  when 
in  this  identical  case  the  thyroid  and 
adrenals,  overworked  during  a  period 
of  years,  steadily  lose  ground  and  be- 
come the  seat  of  organic  changes  which 
inhibit  below  normal  their  secretory 
activity.  The  thyroid  remains  large, 
and  the  tachycardia  continues :  The 
latter  is  no  longer  due  to  excessive  ox- 
idation and  stimulation,  but  to  the  op- 
posite condition,  a  prominent  feature 
of  which  is  low  vascular  tension.  In 
these  cases  there  is  produced  what 
virtually  amounts  to  a  myxedema — all 
the  symptoms  of  which  are  sometimes 
observed.  Thyroid  preparations  are 
then  productive  of  much  good. 

Case  in  a  child  of  4  years  who  six 
months  previously  had  developed 
goiter,  exophthalmos,  and  tachycardia. 
For  eighteen  months  had  had  con- 
,  vulsions,  and  since  the  onset  the 
symptoms  had  been  much  aggravated 
by  an  attack  of  whooping-cough. 
Strophanthus,  bromides,  and  salicy- 
late were  given  with  no  result,  and 
the  child's  condition  was  deplorable, 
when  it  was  put  on  thyroid  extract, 
1  pill  of  0.1  Gm.  (gr.  ij)  a  day.  From 
this  time  there  was  steady  improve- 
ment in  the  condition.  -The  authors 
also  witnessed  cases  in  which  thyroid 
had  done  great  harm.  Leroy  and 
Variot  (Le  progres  medical,  Dec.  14, 
1901). 


In  some  cases,  however,  the  causa- 
tive toxemia  is  of  a  kind  which  can  be 
counteracted  by  means  of  thyroid  prep- 
arations ;  those  in  which,  owing  to  the 
more  or  less  sudden  accumulation  of 
catabolic  products  or  the  retention  of 
such  in  the  blood,  the  thyroid  becomes 
enlarged  owing  to  excitation  of  its 
center.  This  is  a  pseudotype  of  ex- 
ophthalmic goiter,  resembling  patho- 
genically  the  thyroidal  enlargement  ob- 
served in  the  pregnant  woman,  and  due 
to  the  excess  of  waste  products  in  her 
blood  incident  to  the  presence  of  the 
fetus.  There  may  be  slight  tachycardia 
in  these  cases,  but  the  other  symptoms 
of  exophthalmic  goiter  are  absent.  It 
coincides  sometimes  with  delayed  men- 
struation. In  some  cases  the  thyroidal 
enlargement  comes  on  suddenly,  and 
may  be  sufficiently  severe  to  obstruct 
breathing  by  compressing  the  trachea. 
In  all  such  cases  thyroid  preparations 
afiford  decided  benefit  and  may  prove 
curative. 

Of  value  in  this  connection  and  in 
the  same  class  of  cases  as  thyroid  prep- 
arations is  the  Rogers-Beebe  cytotoxic 
serum,  prepared  by  injecting  purified 
nucleoproteids  derived  from  the  thy- 
roid into  animals  of  alien  species.  This, 
according  to  Rogers,  gave  23  cures  in 
90  cases,  while  53  were  improved. 
Here,  from  my  standpoint,  the  serum 
acts  as  antitoxin  in  the  destruction  of 
the  poisons  which,  by  exciting  the 
adrenothyroid  center,  cause  the  disease. 

Results  obtained  in  16  cases  treated 
by  the  serum  :  5,  or  31  per  cent.,  have 
been  cur-ed,  the  oldest  case  having  been 
without  symptoms  for  over  three  years, 
the  last  for  about  six  months.  One  of 
these  cases  was  very  toxic,  her  pulse  be- 
ing over  180  on  exertion,  and  with  a 
great  deal  of  nausea  and  diarrhea. 
Within  six  weeks  she  was  practically 
relieved  of  all  subjective  symptoms,  her 


ANIMAL  EXTRACTS    (SAJOUS). 


1V/ 


pulse  being  reduced  to  about  80.  Seven, 
or  44  per  cent.,  were  markedly  improved 
so  that  their  life  had  been  rendered 
much  more  comfortable,  and  this  im- 
provement apparently  is  permanent. 
Tv^^o  of  these  cases  were  very  serious 
ones,  and  3  have  taken  the  serum  treat- 
ment twice,  with  an  additional  improve- 
ment the  second  time.  Four,  or  25  per 
cent.,  do  not  appear  to  have  made  any 
permanent  improvements,  though  all  of 
these  were  certainly  better  while  under 
the  direct  charge  of  the  authors,  but 
relapsed  more  or  less  promptly  after 
being  sent  home.  Only  1  case  treated 
has  died.  McCaw  Tompkins  (Old 
Dominion  Jour,  of  Med.  and  Surg., 
Oct.,  1909). 

Thyroidectin,  a  preparation  repre- 
senting tlie  blood  of  the  thyroidecto- 
mized  animals,  is  supposed  to  antago- 
nize the  excessive  production  of  thyroid 
secretion,  but  the  reports  have  been 
conflicting.  It  is  probable  that  it  should 
be  used  only  during  the  first  or  sthenic 
stage  of  the  disease — if  the  theory  of 
its  sponsors  is  sound. 

The  writer  has  treated  7  patients 
with  thyroidectin;  3  of  the  cases 
were  very  severe.  In  each  of  these 
cases  rest  in  bed,  the  ice-bag  to  the 
heart,  and  other  remedies,  such  as 
sodium  phosphate  or  strychnine,  have 
been  used  more  or  less  regularly.  All 
the  patients  improved,  but  he  could  not 
see  that  the  process  was  more  rapid  or 
otherwise  different  from  those  treated 
without  thyroidectin,  but  the  same  in 
other  respects.  Dock  (Amer.  Med., 
Feb.  24,  1906). 

Goiter. — In  the  majority  of  cases 
of  goiter  we  are  dealing,  from  my 
viewpoint,  with  a  result  of  overactivity 
of  the  thyroid  mechanism.  This  may 
be  due  either  (1)  to  the  presence  of 
some  toxic  (derived  mainly  from  con- 
taminated water)  in  the  blood,  which 
excites  the  adrenothyroid  center  or  (2) 
to  absence  in  the  air  or  in  the  water  or 
foods  ingested  of  the  iodine  necessary 


to  supply  tlie  thyroid  the  proportion  it 
needs  to  elaborate  its  secretion. 

In  children  and  young  adults  iodine 
or  thyroid  preparations  are  frequently 
beneficial,  therefore,  whereas  in  adults 
in  which  organic  changes  have  occurred 
in  the  enlarged  gland  they  are  seldom 
of  use,  as  far  as  material  reduction  of 
the  goiter  is  concerned.  In  any  case, 
very  small,  even  fractional  doses  should 
be  given  at  first,  whether  thyroid  prep- 
arations or  iodine  be  used,  gradually  in- 
creasing the  dose  if  need  be.  I  have 
seen  a  minute  dose  of  iodine  produce 
untoward  effects.  Cases  in  which  evi- 
dences of  myxedema  and  hypothermia 
are  present  usually  stand  normal  doses 
without  discomfort. 

Efifect  of  iodine  on  natural,  colloid, 
and  actively  hyperplastic  (parenchyma- 
tous) thyroids  of  dogs.  Numerous 
forms  of  iodine  and  iodine-containing 
substances  were  used  in  different  ways. 
Very  small  amounts  were  necessary  to 
induce  thyroid  changes.  The  more 
marked  the  hyperplasia,  the  greater  is 
the  amount  of  iodine  taken  up.  Iodine, 
administered  to  dogs  with  hyperplastic 
thyroids,  acted  like  the  desiccated  thy- 
roid itself,  and  very  beneficial  results 
were  obtained  by  the  use  of  very  small 
doses  gradually  increased  in  these 
hyperplastic  conditions.  Marine  and 
Lenhart  (Archives  of  Intern.  Med., 
Sept.,  1909). 

Series  of  6  cases  in  which  unusually 
small  doses  of  sodium  iodide  in  patients 
with  goiter  induced  symptoms  of  in- 
toxication, the  patients  all  presenting 
the  familiar  picture  of  hyperfunction- 
ing on  the  part  of  the  thyroid  instead  of 
the  anticipated  benefit.  The  total 
amount  given  in  the  course,  of  the 
treatment  ranged  from  1  to  about  7 
Gm.  (15  to  100  grains)  in  the  course  of 
from  ten  to  forty-five  days,  the  daily 
dose  being-  from  0.09  to  0.33  Gm.  In  1 
patient  the  thyroidism  developed  after 
10  daily  doses  of  0.1  Gm.  (1^  grains). 
Analysis  of  the  cases  showed  that  the 
patients  were  all  from  families  with  a 


1-47 


738 


ANIMAL   EXTRACTS    (SAJOUS). 


tendency  to     exophthalmic    goiter,     or 

diabetes,  or      neuropathies.        Pineles 

(Wiener  klin.     Woch.,     March     10, 
1910). 

Hemophilia. — Thyroid  preparations 
are  extremely  valuable  in  this  dyscrasia, 
due  to  a  deficiency  of  fibrin  ferment  in 
the  blood.  As  this  body,  according  to 
my  researches,  is  mainly  composed  of 
the  adrenal  product,  the  increased 
functional  activity  of  the  adrenals  pro- 
voked by  thyroid  preparations  admin- 
istered increases  the  blood's  asset.  The 
coagulation  time  in  hemophilia  may  be 
brought  down  from  over  ten  minutes 
to  three  or  four  minutes  in  adults  by 
3-grain  doses  of  the  desiccated  thyroid 
three  times  daily  after  meals.  This  is 
effective  not  only  in  the  treatment  of 
the  disease,  but  also  when  operations 
are  necessary  in  hemophilics.  Even 
such  operations  as  removal  of  a  kidney 
have  been  resorted  to  with  perfect 
safety  after  the  coagulation  time  had 
been  reduced  to  three  minutes. 

Case  in  which  hemophilic  epistaxis 
was  absolutely  unaffected  by  ordinary 
therapeutic  agents,  and  the  epistaxis  be- 
came so  persistent  and  exhausting  that 
permanent  blocking  of  the  nasal  fossa 
was  necessary.  Treatment  by  thyroid 
extract  exerted  an  immediate  and  bene- 
ficial efifect,  and  was  followed  by  cure. 
In  three  days  the  violent  and  persistent 
epistaxis  had  practically  stopped.  In  six 
days,  about  8  'grains  of  thyroid  extract 
having  been  given  daily,  the  purpuric 
eruption  ceased.  Scheffler  (Archives  de 
med.  et  de  pharm.  Mil.,  March,  1901). 
Three  cases  of  operations  in  "bleed- 
ers" in  which  the  administration  of 
thyroid  extract,  for  some  days  preced- 
ing operation,  as  advised  by  Sajous,  was 
followed  by  remarkable  results  in  les- 
sening the  hemorrhage  at  that  time. 
Sajous  holds  that  the  thyroid  extract 
stimulates  the  anterior  pituitary  body, 
which  in  turn  excites  the  adrenals  to 
greater  activity,  thus  augmenting  the 
proportiori    of    fibrin    ferment    in    the 


blood,  and  consequently  its  coagulating 
power.  This  explams  the  action  in 
these  hemophilics,  and  its  use  is  recom- 
mended as  a  preparatory  treatment 
whenever  surgical  operation  is  to  be 
undertaken  in  such  persons.  W.  J. 
Taylor  (Monthly  Cycle,  of  Pract.  Med., 
July,  1905). 

Incontinence  of  Urine. — In  a  large 
number  of  these  cases,  the  enuresis  is 
due  to  general  asthenia,  and  the  mus- 
cular debility  which  attends  this  state 
carries  along  with  it  inability  of  the 
sphincters  to  perform  their  functions 
at  all  times,  especially  when  during 
sleep  general  relaxation  prevails.  The 
influence  of  thyroid  on  general  me- 
tabolism and  nutrition  and  the  result- 
ing increase  of  functional  power  in 
all  organs  affect  equally  both  the 
cystic  and  urethral  sphincters  and 
thus  overcome  the  trouble.  The  doses 
should  be  small  in  order  to  enhance 
general  nutrition. 

Nocturnal  incontinence  of  urine  in 
young  children  and  adolescents  is  due 
to  thyroid  insufficiency.  Several  cases 
in  which  the  use  of  thyroid  extract  was 
followed  by  improvement  or  cure. 
Children  who  suffer  from  incontinence 
are  almost  always  undersized,  and  they 
present  the  infantile  habitus  in  varying 
degrees — improperly  placed  teeth,  naso- 
pharyngeal adenoid.s,  flat  chests,  and 
emaciated  and  slender  extremities. 
Such  patients  are  often  flat-footed  and 
their  feet  have  an  offensive  odor,  their 
gait  is  stiff,  they  suffer  from  pains  in 
the  thighs  and  from  sciatica  produced 
by  the  cold  and  moist  surroundings  in 
which  they  lie  at  night.  The  systematic 
examination  of  the  urine  in  these  cases 
shows  an  abundant  deposition  of  the 
cells  covering  the  free  surface  of  the 
mucous  membrane  of  the  bladder.  In 
children  beyond  2  years  of  age  the 
writer  gives  3  S-grain  tablets  of  thyroid 
per  iveek,  with  from  3  to  5  grains  of 
potassium  iodide  and  bromide  daily. 
Hertoghe  (Bull,  de  I'Acad.  Royale  de 
med,  Belgique,  xxi,  No.  4,  1907). 


ANIMAL   EXTRACTS    (SAJOUS). 


739 


Case  in  which  the  writer  had  the 
adenoids  of  a  9-year-old  boy  removed, 
hoping  it  would  cure  him  of  nocturnal 
incontinence.  It  made  the  boy  much 
worse,  however,  and,  believing  that  the 
removal  of  the  adenoids  deprived  the 
boy  of  a  necessary  internal  secretion,  he 
then  gave  him  thyroid  extract,  ^  grain 
twice  daily.  The  result  was  instanta- 
neous and  complete,  the  boy  no  further 
wetting  the  bed.  Twenty-four  other 
cases  were  thus  treated,  with  but  one 
failure.  Williams  (Lancet,  May  1, 
"  1909). 

Infectious  Diseases. — So  far  thy- 
roid preparations  have  not  been  used 
to  any  marked  extent  in  this  class  of 
disorders,  but  it  is  probable  that  they 
will  eventually  prove  of  great  value 
owing  to  the  identity  of  the  thyroid 
secretion  as  opsonin,  pointed  out  by 
myself  in  1907,  as  previously  stated. 
Several  investigators,  including  ]\Iarbe, 
of  the  Pasteur  Institute,  have  since 
found  that  the  administration  of  thy- 
roid preparations  to  animals  increased 
the  opsonic  power  of  the  blood. 

There  are  autoinfections  which  de- 
velop within  the  organism  as  the  result 
of  w^eakening  of  the  organic  defensive 
forces  and  exalted  virulence  of  the 
ordinary  saprophytic  microbes.  It  is 
probable  that  certain  specific  infectious 
diseases,  such  as  diphtheria,  tj'phoid 
fever,  and  others,  are  likewise  of  auto- 
genic origin.  The  organism  is  con- 
stantty  fighting  against  its  parasites,  by 
weakening  them  and  finally  destroying 
them  through  the  phagocytes.  The  op- 
sonins of  the  tissue  juices  and  exudates, 
by  acting  upon  the  microbes  and  upon 
phagocytosis,  assist  in  the  natural  de- 
fenses of  the  organism.  These  op- 
sonins, which  seem  to  become  one  with 
the  alexins,  are  to  a  considerable  extent 
the  product  of  the  thyroid  gland. 
Stepanoff   (These  de  Paris,  1908). 

"Sajous  has  attributed,  among  the 
functions  of  the  thyroid  body,  a  role 
to  the  latter  which  he  assimilates  to 
that  of  opsonins  and  to  autoanti- 
toxins.     More  recently,   Miss  Fassin, 


M.  StepanofY,  and  M.  Mar()e  have 
confirmed  on  their  side  the  influence 
of  the  thyroid  on  the  blood's  asset  in 
alexins  and  opsonins."  ("Physiopa- 
thologie  du  Corps  Thyroide,"  p.  20, 
Paris,  1911.) 

The  enlargement  of  the  thyroid, 
which  can  be  distinctly  detected  by  pal- 
pation, and  its  erethism  during  infec- 
tious and  other  toxemias  indicate  that 
it  fulfills  active  functions  in  the  im- 
munizing process. 

After  removal  of  the  thyroid  gland 
the  urine  contains  a  greater  percentage 
of  poisonous  matter  than  that  of  healthy 
animals  does ;  the  urotoxic  coefficient 
begins  to  rise  gradually,  even  before 
the  nervous  symptoms  attributable  to 
the  operation  set  in ;  animals  that  are 
kept  without  food  also  show  an  in- 
creased toxicity  of  the  urine;  the  ad- 
ministration of  thyroid  juice  is  capable 
of  first  moderating  the  increment  of 
urinary  toxicity  and  then  reducing  the 
toxicity ;  accordingly,  in  the  organism 
of  a  dog'that  has  been  deprived  of  the 
thyroid  gland  there  are  toxic  materials 
in  excess,  and  thyroid-gland  juice  serves 
to  neutralize  them.  De  Lucca  and 
d'Angerio  (Rivista  medica  therapeutica, 
No.  9,  1896). 

There  is  hypersecretion  of  colloid 
substances  in  the  gland  in  acute  or 
chronic  infective  diseases,  as  well  as 
marked  epithelial  proliferation  and  an 
abundant  neoformation  of  glandular 
tissue.  Interstitial  inflammatory  proc- 
esses, such  as  abscesses  and  tubercles, 
are  rarely  met  within  the  gland.  The 
colloid  substance  has  the  property  of 
destroying  micro-organisms.  The  epi- 
thelial proliferation  and  the  hypersecre- 
tion of  colloid  substances  are  due  to 
a  toxic  product  of  the  infective  process, 
perhaps  caused  by  destruction  of  the 
micro-organisms  by  colloid  substance, 
or  brought  to  the  gland  by  the  circulat- 
ing blood.  Odoacre  Torri  (II  Poli- 
clinico,  May  15,  1900). 

Examination  of  55  thyroids  of  which 
38  were  taken  from  persons  dead  of  in- 
fectious diseases.  As  a  means  of  com- 
parison 17  were  taken  from  persons  in 


740 


ANIMAL   EXTRACTS    (SAJOUS). 


whom  death  was  due  to  other  causes. 
Of  the  infectious  diseases  thus  studied 
6  were  diphtheria,  6  scarlet  fever,  5 
miliary  tuberculosis,  5  measles,  4  fibri- 
nous pneumonia,  3  puerperal  fever,  2 
typhoid  fever,  2  septicemia,  and  5  pul- 
monary tuberculosis.  In  the  majority 
of  infective  diseases  the  interstitial 
lymph-vessels  show  an  accumulation  of 
colloid  material.  S.  Kashiwamura 
(Virchow's  Archiv,  Bd.  166,  H.  3, 
1901). 

Thyroid  feeding  renders  white  mice 
much  less  susceptible  to  the  toxic  action 
of  acetonitrile,  but  has  no  effect  on  the 
toxic  dose  of  sodium  nitroprusside  or 
of  hydrocyanic  acid.  This  indicates  that 
the  thyroid  preparation  does  not  act  by 
increasing  sulphur  compounds  by  metab- 
olism of  proteids,  but  by  some  specific 
antitoxic  power.  Proteids  (such  as 
casein,  nutrose,  peptone),  nuclein,  and 
preparations  of  the  thymus  and  of  the 
suprarenal  glands  counteract  to  some 
extent  the  neutralizing  or  protective 
power  of  thyroid  gland  against  aceto- 
nitrile. Thyroidectin  increased  slightly 
the  susceptibility  of  mice  to  acetonitrile. 
Reid  Hunt  (Jour,  of  Biol.  Chemistry, 
vol.  i,  No.  1,  1906). 

In  infectious  diseases  a  slight 
swelling  of  one  or  both  lobes  is 
common,  pain  being  elicited  by  the 
pressure  of  the  fingers.  In  acute 
articular  rheumatism  it  was  found  in 
53.6  per  cent,  of  cases.  It  is  also 
found  in  typhoid  fever,  measles,  scar- 
latina, secondary  syphilis,  mumps, 
and  other  diseases.  Curiously,  how- 
ever, it  is  absent  in  many  grave 
infectious  diseases,  such  as  septi- 
cemia, ataxoadynamia,  and  gangrene. 
It  looks  as  if  enlargement  of  the 
thyroid  in  various  infections  were  the 
expression  of  a  defensive  reaction 
against  their  pathogenic  agents  and 
their  toxins.  Vincent  (Comptes-ren- 
dus  de  la  Societe  Medicale  des  Hop- 
itaux,  1906). 

[The  participation  of  the  thyroid  in  gen- 
eral immunity  pointed  out  by  myself  in 
1903  and  since  confirmed,  we  have  seen, 
explains  the  overactivity  of  the  thyroid  in 
certain    disorders,      But,    as    I    have    re- 


peatedly employed  in  "Internal  Secre- 
tions," vol.  ii,  this  applies  only  to  those 
diseases  which  are  capable  through  their 
toxins  of  exciting  the  thyroadrenal  center, 
thus  evoking  a  protective  reaction  on  the 
part  of  the  thyroid  and  adrenals.  Various 
toxins  and  poisons  are  not  only  unable  to 
excite  this  center,  but  can  depress  it. 
Hence  the  fact  that  in  the  conditions  men- 
tioned (excepting  septicemia,  in  which 
Vincent  is  wrong  in  his  generalization) 
the  thyroid  gives  no  evidence,  through 
tumefaction  and  tenderness,  of  over- 
activity.    C.  E.  DE  M.  S.] 

So  far,  thyroid  preparations  have 
been  used  in  but  few  diseases.  In 
true  infectious  tonsillitis,  desiccated 
thyroid  clears  the  field  promptly.  It 
does  so,  of  course,  by  enhancing  the 
bactericidal  and  antitoxic  powers  of 
the  blood  and  glandular  secretions. 
The  bacteria  being  rendered  more 
sensitive,  that  is  to  say,  more  easily 
digestible,  they  readily  become  the 
prey  of  the  phagocytes,  which  are  ex- 
tremely numerous  in  the  tonsils. 
Thyroid  gland  has  also  been  em- 
ployed advantageously  in  septicemia 
and  in  recurrent  erysipelas,  i.e.,  in 
streptococcic  infection. 

Acute  infectious  disease,  especially 
scarlet  fever,  can  awaken  changes  in 
the  thyroid  gland,  a  hyperemia,  liquefac- 
tion and  disappearance  of  the  colloid 
substance,  and  desquamation  of  the 
epithelium.  The  connective  tissue  is 
not  altered.  J.  Sarbach  (Mitt.  a.  d. 
Grenzgebieten  der  Med.  u.  Chir.,  Bd. 
XV,  Nu.  3  u.  4,  1906). 

Examination  of  the  thyroid  gland  in 
7  cases  of  septicemia.  A  hypersecretion 
of  the  colloid  substance  was  found  to 
take  place  coincidently  with  acute  or 
chronic  infections.  In  the  acute  cases 
a  marked  proliferation  of  the  epithe- 
lium was  observed,  whereas  the  chronic 
cases  were  characterized  by  an  active 
new  formation  of  follicles  with  sclerosis 
of  the  connective  tissue.  No  bacteria 
could  be  demonstrated  in  the  colloid 
gubstance.     It  is  probable  that  the  col- 


ANIMAL  EXTRACTS    (SAjOUS). 


741 


loid  substance  has  a  favorable  influence 
upon  infectious  processes.  Monaco 
(Giorn.  Med.  del  Regio  Esercito,  No.  1, 
1907). 

Case  of  a  young  woman  in  whom 
severe  erysipelas  had  recurred  twenty- 
two  times  and  in  whom  areas  of  ulcera- 
tion on  both  legs  had  suggested  syphilis. 
Under  thyroid  treatment  the  attacks  of 
erysipelas  ceased.  This  suggests  that 
thyroid  facilitates  immunity  against 
streptococcus  infection,  as  it  does  in 
.  autoinfections,  such  as  recurrent  tonsil- 
litis. Leopold-Levi  (Bull,  med.,  July 
29,  1911). 

Pulmonary  tuberculosis,  before  the 
disease  is  sufficiently  advanced  to 
compromise  the  mechanism  of  respi- 
ration, that  is  to  say,  during-  the  first 
or  incipient  stage,  is  especially  vul- 
nerable to  the  action  of  small  doses 
of  thyroid.  As  I  urged  in  1907,  the 
tubercle  bacillus,  which  is  also  patho- 
genic when  dead,  owes  its  morbid  ac- 
tion to  an  endotoxin  rich  in  phos- 
phorus; being  thus  prone  to  oxidation, 
while  the  blood's  oxidizing  power  is 
enhanced  simultaneously,  this  bacillus 
is  promptly  destroyed. 

The  daily  administration  of  thyroid 
gland  at  a  time  corresponding  to  or 
preceding  infection  with  tuberculosis, 
and  in  such  doses  as  are  well  borne, 
causes  an  energetic  acceleration  of 
the  metabolism  of  the  organism  and 
modifies  favorably  the  action  of  the 
experimental  tuberculous  and  pseudo- 
tuberculous infection  in  rabbits.  The 
animals  treated  with  thyroid  gland 
live  longer  than  the  control  animals, 
and  in  some  cases  life  is  prolonged 
indefinitely.  Frugoni  and  Grixoni 
(Berl.  klin.  Woch.,  June  21,   1909). 

As  stated  above,  it  is  only  in  the 
incipient  stage  that,  as  shown  by  per- 
sonal experience,  thyroid  gland  is 
useful  to  check  the  morbid  process. 
Later,  it  produces  exhaustion  owing 
to  the  excessive  catabolism  it  awak- 
ens, even  in  very  small  doses. 


Insanity. — The  idiocy  of  cretinism 
and  the  wonderful  improvement  that 
thyroid  preparations  bring  about  in 
young  cretins  suggest  that  a  direct  re- 
lationship must  exist  between  the  func- 
tion of  the  thyroid  and  the  organ  of 
mind,  the  brain.  The  functions  I  have 
ascribed  to  the  thyroid  to  increase  the 
vulnerability  of  phosphorus-laden  cells, 
etc.,  to  oxidation  explain  this  beneficial 
action.  Briefly,  the  thyroid  preparation 
raises  the  ability  of  the  cerebral  cells 
to  replace  the  sluggish  metabolism  and 
inadequate  nutrition  of  which  it  has 
ben  the  seat  to  the  level  of  normal  me- 
tabolism and  nutrition.  In  other  words, 
the  cerebral  cells,  along  with  those  of 
the  entire  organism,  are  caused  to 
burn  faster ;  the  vital  process  being  cor- 
respondingly more  active,  the  function 
of  the  brain,  as  the  seat  of  mental  proc- 
esses, is  sooner  or  later  in  young  sub- 
jects carried  on  with  adequate  vigor. 

Andriezen,  of  London,  who  has  in- 
vestigated autotoxis  in  relation  to 
insanity  and  especially  acromegaly, 
called  attention  to  an  important 
diathetic  class  of  insanities  which  the 
textbooks  as  yet  have  not  recognized. 
"He  did  not  refer  to  the  so-called 
gouty  or  rheumatismal  insanities,  but 
to  those  associated  with,  and  growing 
in  the  soil  of,  myxedema  and  acro- 
megaly, with  a  very  constant  and 
distinct  physiognomy  of  their  own, 
•and  a  pathogenesis  that  could  be 
harmonized  and  well  explained  by 
the  morbid  changes  present,  changes 
which  lay  at  the  root  of  the  mental 
as  well  as  the  bodily  conditions.  In 
the  one  case  (myxedema),  a  morbid 
process  starting  from  the  thyroid  gland 
affected  the  whole  capacity  of  the  blood 
in  regard  to  its  power  of  taking  up  oxy- 
gen from  the  air.  On  examining  the 
blood  with  the  mercurial  pump  it  was 
found  that  its  oxygen  and  carbonic  acid 
were  much  diminished,  and  by  placing 
the  individual  in  the  apparatus  for  ex- 
amining the  gases  of  respiration  it  was 


HI 


ANIMAL  EXTRACTS    (SAJOUS). 


found  out  that  he  took  in  but  little 
oxygen  and  correspondingly  gave  out 
but.  little  carbonic  acid  during  life. 
Thus  he  suffered  from  weakness  and 
dullness,  from  subnormal  temperature, 
and  from  a  tendency  to  the  accumula- 
tion of  incompletely  oxidized  bodies 
(fat,  etc.)  in  his  tissues."  A.  McLane 
Hamilton  (Medical  Record,  April  29, 
1899). 

The  psychical  disorders  due  to  thy- 
roid insufficiency  may  be  associated  with 
the  following:  infantilism,  physical 
and  mental  backwardness,  Hertoghe's 
chronic  hypothyroidal  syndrome,  hypo- 
thyroidal  temperament,  hypothyroidal 
neurasthenia.  Laignel-Lavastine  (Le 
bulletin  medical,  Aug.  S,  1908). 

Case  of  insanity  in  a  myxedematous 
woman  who  was  given  for  a  week 
tablets  prepared  from  the  thyroid  of 
the  sheep.  At  the  end  of  that  brief 
period  she  was  transformed  from  a 
sjupid  object  into  a  bright  and  pleasant 
featured  woman,  quite  unrecognizable 
as  the  creature  of  a  week  before. 

Second  case  of  insanity  due  to  an 
excess  of  the  thyroid  secretion  in  the 
blood,  manifested  by  great  nervousness 
and  excitability  and  many  other  symp- 
toms, such  as  palpitation ;  there  is  a 
theory,  not  yet  established,  that  excess 
of  thyroid  secretion  is  neutralized 
by  some  substance  in  the  blood,  of 
which  substance  (according  to  theory) 
there  was  not  sufficient  to  neutralize 
the  great  excess ;  the  patient  was, 
therefore,  supplied  with  serum  (supra- 
renal extract?)  from  a  goat  whose  thy- 
roid had  been  removed.  Apparently  as 
a  result  of  this  treatment  a  good  re- 
covery was  made.  S.  M.  Robertson 
(Medical  Times,  August,  1911). 

Such  being  the  case,  we  can  only  ex- 
pect benefit  when  increased  metabo- 
lism and  cell  nutrition  is  required,  i.e., 
in  stuporous  melancholias  due  to  de- 
fective nutrition,  depressive  states  in 
general,  when  organic  lesions  are  not 
present.  Again,  in  view  of  the  prop- 
erty thyroid  preparations  possess  of 
promoting  the  proteolysis  or  breaking 


down  of  waste  products  we  should  ex- 
pect benefit  in  puerperal  and  climac- 
teric insanities.  Clinical  observation 
has  sustained  this  interpretation.  As 
a  rule,  however,  psychiatrists  have  used 
entirely  too  large  doses ;  hence,  the  un- 
toward eft'ects  recorded. 

Trial  of  thyroid  in  130  patients  whose 
insanity  was  definitely  making  no 
progress  toward  recovery  under  the 
methods  adopted  in  the  asylum,  or 
whose  insanity  was  becoming  chronic 
or  incurable.  Each  patient  was  put 
to  bed  during  the  period  of  experi- 
ment, and  was  given  a  staple  diet 
sufficient  to  maintain  body  weight  at 
its  usual  level,  the  administration  of 
the  extract  beginning  on  the  hft.i 
da3^  The  patient  was  weighed  weekly 
during  treatment  and  for  a  month 
after.  The  urine  was  regularly  ex- 
amined, and  the  urea  was  estimated 
by  the  hypobromite  method.  The 
phosphates  in  the  urine  were  de- 
termined by  the  uranium  method. 
The  thyroid  extract  was  administered 
in  130  cases  of  insanity  (45  males  and 
85  females)  with  the  following  results : 
AVhere  large  doses  were  given  there  fol- 
lowed pyrexia  in  most  of  the  cases  to  a 
slight  or  moderate  degree.  Loss  of 
weight  was  a  constant  symptom ;  also 
increased  sweating,  pains  and  tinglings 
in  various  parts  of  the  body,  and  a 
slight  or  moderate  degree  of  exaltation, 
or  restlessness.  There  was  tachycardia 
in  most  cases,  and  the  respirations  were 
increased  by  about  six  per  minute. 
Appetite  and  thirst  increased,  and  in 
females  menstruation  was  made  more 
profuse  than  usual.  Urea  and  nitrog- 
enous products  were  increased  in  the 
urine,  showing  an  enhanced  metabolic 
activity.  Slight  transitory  albuminuria 
was  found  in  10  per  cent,  of  the  cases. 
In  moderate  and  small  doses  the  above 
results  were  present  in  a  correspond- 
ingl}^  less  degree,  and  it  was  concluded 
that  the  thyroid  extract  acted  as  a 
powerful  metabolic  (catabolic)  stimu- 
lant. The  patients  included  5  idiots 
and  imbeciles,  7  pubescent  or  adoles- 
cent cases,  and  cases  of  mania,  melan- 


ANIMAL   EXTRACTS    (SAJOUS). 


743 


cholia,  mj'xedema,  alcoholic  and  gen- 
eral paralytic  insanity,  etc.  Of  a  total 
of  130  patients,  12  recovered,  29  were 
improved,  and  89  were  unimproved. 
The  recoveries  included  4  cases  of 
stupor,  3  of  puerperal  mania,  1  of  lac- 
tational melancholia,  1  of  myxedema, 
1  of  simple  melancholia,  and  2  of 
climacteric  melancholia.  These  pa- 
tients also  improved  physically.  The 
threatened  attacks  of  folic  circulaire 
were  aborted  by  thyroid  administra- 
tion. C.  C.  Easterbrook  (Lancet, 
Aug.  25,  1900). 

Twenty-two  patients  treated  with  thy- 
roid extract,  administered  in  the  form 
of  S-grain  tablets.  The  dose  was  grad- 
ually increased  from  10  grains  daily  to 
as  much  as  60  grains  in  some  severe 
and  otherwise  intractable  cases,  and 
continued  until  reaction  occurred.  In 
all  cases  the  patients  were,  confined  to 
bed  during  treatment,  were  most  care- 
fully nursed,  and  constant  observations 
of  pulse  and  temperature  recorded. 
The  treatment  was  discontinued  when 
a  noticeable  rise  of  temperature  or  in- 
creased pulse  rate  was  produced.  In  no 
case  has  the  writer  had  any  accident  or 
reason  to  suspect  that  the  patient  was 
unfavorably  influenced  by  the  treat- 
ment. In  1  case,  which  he  considered 
from  the  first  a  rather  unfavorable  one 
for  treatment,  a  severe  gastric  crisis 
seemed  to  have  resulted  from  the  ad- 
ministration of  the  substances.  This 
was  the  case  of  a  girl  with  a  neurotic 
inheritance  who  was  partially  demented 
and  suffered  from  a  large  goiter.  The 
treatment  entirely  removed  the  large 
goiter,  but  failed  to  produce  any  change 
in  the  mental  state. 

Of  22  cases  treated  suffering  from 
various  forms  of  mental  trouble,  7  were 
males  and  15  females.  Three  of  the 
men  completely  recovered,  and  2  of 
these  3  patients  were  homicidal  to  a 
marked  degree. 

The  author  has  treated  3  patients  in 
all  suffering  from  homicidal  impulses 
with  thyroid  extract.  In  all  of  these  3 
cases  a  marked  change  took  place  sub- 
sequent to  the  thyroid  treatment,  and 
the  morbid  impulses  seemed  to  be  lost. 


Of  the  22  patients  treated  by  the  au- 
thor with  sheep's  thyroid,  12  recovered 
and  were  discharged  from  the  hospital, 
and  have  not  since,  so  far  as  he  can  as- 
certain, been  treated,  with  one  excep- 
tion, elsewhere  or  required  readmission 
to  St.  Patrick's  Hospital.  Leeper  (Med. 
Press  and  Circular,  July  5,  1905). 

Two  cases  of  dementia  prsecox 
treated  with  thyroid.  The  first  case, 
which  was  of  the  hebephrenic  type, 
was  completely  cured,  while  the  sec- 
ond, in  which  catatonia  prevailed,  was 
only  temporarily  benefited,  the  treat- 
ment being  stopped  after  recurrence 
of  the  dementia.  The  best  results 
are  to  be  expected  in  the  hebephrenic 
type.  Levison  (Hospitalstidende,  No. 
36,  1909). 

Case  illustrating  the  use  of  thyroid 
extract  in  violent  dementia  prascox. 
The  patient,  aged  22,  was  always  more 
or  less  violent.  When  unwell  she  was 
more  violent  and  troublesome  than 
usual,  repeatedly  asking  for  a  knife  to 
cut  her  throat.  The  habits  were  very 
dirty,  everything  being  passed  in  bed. 
She  was  very  troublesome  with  food, 
having  to  be  spoon-fed. 

On  January  19th  the  treatment  by 
thyroid  tabloids  (5  grains  in  each)  was 
begun.  The  intention  was  to  increase 
the  number  of  tabloids  till  such  time  as 
the  pulse  showed  that  it  would  be 
dangerous  to  give  more,  then  suddenly 
to  cease,  and  thus  produce  a  crisis — 
the  method  usually  adopted  in  such 
cases. 

On  the  19th  3  tabloids  were  given, 
and  the  number  increased.  When  six 
tabloids  a  day  were  given,  the  patient 
began  to  get  more  restless  and  trouble- 
some, and  had  to  have  special  attention 
to  prevent  her  getting  into  harm's  way. 
The  pulse,  at  first  80,  had  now  risen  to 
100.  The  restless  condition  increased 
as  the  number  of  tabloids  increased 
till  the  6th  of  February,  when  she  was 
having  11  a  day.  The  pulse  was  132, 
very  compressible,  but  regular.  She 
now  began  to  speak  sensibly,  to  take 
more  interest  in  her  surroundings,  to 
have  more  control  over  her  conduct, 
lying    quietly    in    bed,    and    to    become 


HA 


ANIMAL  EXTRACTS    (SAJOUS). 


cleaner  in  her  habits.  On  the  10th  the 
pulse  was  150,  the  number  of  tabloids 
12,  and  the  mental  condition  was  im- 
proving. The  thyroid  was  then  grad- 
ually reduced.  The  number  of  tabloids 
was  maintained  at  12  for  some  days, 
then  gradually  decreased  with  steady 
improvement  in  the  mental  state,  ex- 
cept at  5,  when  the  patient  became  very 
restless  and  sleepless.  Sulphonal,  gr. 
15,  was  given  on  three  successive  nights, 
with  good  results,  and  she  again  con- 
tinued to  improve.  '  On  the  1st  of 
March  she  was  able  to  get  out  of  bed 
for  a  few  hours,  but  great  care  had  to 
be  taken  to  prevent  any  undue  exertion. 
She  got  gradually  stronger,  and  was 
able  to  go  to  the  country  on  the  10th 
of  March.  She  was  then  taking  1  tab- 
loid a  day,  but  this  has  now  ceased. 
The  pulse  when  she  left  was  still  about 
120,  but  was  of  fair  strength.  No  in- 
convenience was  caused,  though  she 
had  to  be  prevented  from  unduly  ex~ 
erting  herself.  The  pulse  has  now  come 
down  to  nearly  normal.  The  mental 
improvement  has  continued,  and  she 
is  now  very  bright,  has  lost  all  her  shy- 
ness and  dread  of  strangers,  has  taken 
up  her  music  and  painting,  and  is  more 
her  natural  self  than  she  has  been  for 
some  time.  A.  Davidson  (Austral. 
Med.  Gaz.,  April  20,  1911). 

Lactation. — Thyroid  preparations 
have  been  recommended  as  galacta- 
gogues  by  Hertoghe,  Cheron,  and  oth- 
ers. In  some  cases  on  record  the  secre- 
tion of  milk  was  free  as  long  as  thyroid 
was  taken  and  failed  as  soon  as  it  was 
neglected.  This  is  obviously  due  to  its 
stimulating  influence  on  general  oxida- 
tion, all  functions  being  enhanced. 

The  value  of  the  administration  of 
thyroid  as  a  means  of  increasing  the 
activity  of  the  mammary  glands  had 
already  been  demonstrated  by  Hertoghe 
in  1900  in  patients  presenting  mild 
symptoms  of  thyroid  insufficiency.  The 
writer  confirms  the  ^  latter's  observa- 
tions, but  believes  that  the  period  of 
lactation  is  not  the  best  time  during 
which  to  begin  the  thyroid  medication. 
He  has   obtained  better  results  by  be- 


ginning the  treatment  in  the  early 
months  of  pregnancy,  during  the  time 
when  the  mammary  glands  are  trans- 
forming from  a  state  of  rest  to  one 
of  activity.  This  therapeutic  measure 
is  recommended  particularly  in  women 
who  have  already  given  evidence  of 
inability  to  nurse  their  children  wholly 
or  in  part.  The  dose  of  thyroid  ad- 
ministered is  about  0.1  Gm.  (1^^  grains) 
from  one  to  three  times  a  day.  The 
result  of  this  treatment  is  a  copious 
secretion  of  milk  after  the  birth  of  the 
child.  A.  Siegmund  (Zentralbl.  f. 
Gynak.,  Oct.  IS  and  22,  1910). 

Middle-ear  Disorders.  —  Thyroid 
preparations  have  been  tried  in  several 
of  these  disorders,  sclerosis,  middle-ear 
catarrh,  ossicular  sclerosis,  etc.,  but  the 
results,  on  the  whole,  were  not  encour- 
aging. They  should  be  tried,  however, 
in  suppurative  processes  associated 
with  general  adynamia,  as  these  often 
persist  merely  because  the  bactericidal 
and  antitoxic  powers  of  the  blood  are 
deficient.  Thyroid,  by  enhancing  these 
protective  functions,  has  at  least  proven 
valuable  in  ulcerative  disorders  located 
elsewhere,  even  when  osseous  tissue 
was  involved,  as  in  osteomyelitis. 

Nervous  Disorders.  —  Epilepsy.  — 
This  disease  is  sometimes  greatly  bene- 
fited by  the  use  of  thyroid  prepara- 
tions, but  only  when  small  doses  are- 
used.  Untoward  results  are  readily 
caused  by  excessive  dosage,  as  shown 
by  loss  of  weight.  Coincidently,  meat 
should  be  removed  from  the  diet,  and 
the  patient  ordered  to  drink  copiously 
of  water.  The  spasmogenic  wastes  are 
thus  increasingly  broken  down  by  the 
thyroid;  they  are  formed  less  freely 
owing  to  the  abstraction  of  meat,  and 
the  end  products  of  metabolism  are 
more  readily  eliminated  by  the  kidneys 
owing  to  the  free  use  of  water.  I  have 
observed  excellent  results  through  this 
treatment.     It    must    not    be    forgot- 


ANIMAL   EXTRACTS    (SAJOUS). 


745 


ten,  however,  that  other  factors — 
intestinal  worms,  indigestible  foods, 
scars,  dentition,  alcohol,  lead  poison- 
ing, syphilis,  nasal  growths,  dental 
interpressure,  and  phimoses — may  pro- 
duce epilepsy,  and  that  the  cause  must 
be  removed  in  such  cases  if  a  satisfac- 
tory result  is  to  be  obtained. 

Case  of  epileptic  idioc3^with  diffuse 
lipomata,  ichthyosis,  and  nevi  success- 
fully treated  with  thyroid  extract.  In 
this  typical  case,  the  thyroid  extract 
supplied  the  exact  want;  the  ichthyosis 
almost  disappeared,  the  lipomata  de- 
creased in  size,  and  the  intelligence  of 
the  boy  improved.  Whether  or  not  the 
congenital  absence  of  the  thyroid  gland 
is  the  primary  cause  of  all  his  symptoms 
is  at  present  difficult  to  say,  although 
the  marked  improvement  strongly  points 
in  that  direction.  Nathan  Raw  (Jour, 
of  Mental  Sci.,  Oct.,  1897). 

In  the  young  there  occurs  a  class  of 
cases  characterized  by  recurrent  attacks 
of  a  heterogeneous  type,  that  may  con- 
veniently be  called  "pseudoepilepsy."^ 
This  form  is  curable.  Such  cases,  so 
far  as  here  studied,  are  due  to,  or  asso- 
ciated with,  disturbances  in  the  general 
tissue  metabolism  of  the  body.  Some 
of  these  are  in  whole  or  in  part  of 
rachitic  origin.  Troubles  of  this  kind 
when  due  to  rachitis  are  amenable  to 
thyroid  treatment.  True  epilepsy  is  not 
remedied  by  thyroid,  even  in  a  person 
who  was  once  rachitic.  It  is  evident 
that  in  many  cases  there  is  a  closer  re- 
lationship between  rachitis  and  athyrosis 
than  has  heretofore  been  recognized. 
There  must  be  a  relative  inadequacy  of 
the  thyroid  function  in  those  cases  asso- 
ciated with  rickets.  Either,  as  one  of 
the  author's  cases  indicates,  there  is  a 
serious  impairment  of  the  activity  of 
the  gland  or  thyroid  feeding  serves  to 
burn  up  harmful  material  at  large  in 
the  system.  William  Browning  (Jour. 
Nerv!  and  Mental  Dis.,  Oct.,   1902). 

Case  of  a  man  aged  20  who  began 
to  suffer  from  epileptic  fits  and  simul- 
taneously enlargement  of  the  thyroid 
gland.  Two  years  of  bromide  had  no 
effect.     Treatment  of  the  thyroid  with 


electricity  and  iodine  brought  about  a 
reduction  in  size  of  the  thyroid  and 
complete  cessation  of  fits.  The  positive 
electrode  was  wrapped  in  wool,  soaked 
in  iodine,  and  applied  to  the  gland. 
Other  writers  have  proved  that  there 
is  a  definite  relationship  between  epi- 
lepsy and  the  thyroid,  and  this  is  sup- 
ported by  experiments  on  animals. 
Crisafulli    (II  Morgagni,  April,   1903). 

A  conclusion  forces  itself  upon  us, 
viz.,  that  idiopathic  epilepsy  is  always 
associated  with  defective  metabolic 
processes.  The  latter  may  originate 
from  many  sources.  There  is  a  certain 
class  of  epileptics  whose  seizures  are  in 
direct  relationship  with  a  disturbed 
function  of  the  ductless  glands  and 
particularly  the  thyroid.  In  such  cases 
the  reason  for  failure  of  the  usual 
treatment  lies  in  the  want  of  thyroid 
feeding.  Administration  of  the  latter 
will  be  of  great  benefit.  Six  illustrative 
cases.  Alfred  Gordon  (Penna.  Med. 
Jour.,  July,  1908). 

Three  cases  of  epilepsy  in  which  the 
simplifying  influence  of  Dr.  Sajous's 
discoveries  as  to  the  functions  of  the 
ductless  glands  and  other  body  struc- 
tures is  clearly  shown  by  good  results. 
All  three  being  due  to  the  retention  of 
excrementitious  substances  in  the  blood, 
and  the  irritating  action  of  these 
poisons  upon  the  spasmogenic  centers— 
the  indications,  of  course,  were  to 
destroy  these  poisons.  Drugs  known  to 
do  so  by  increasing  the  antitoxic  sub- 
stances through  the  ductless  glands — 
mercury  and  desiccated  thyroid — were 
administered.  To  assist  this  antitoxic 
process  of  the  osmotic  properties  of  the 
blood,  physiological  saline  solution  was 
given  as  beverage.  On  the  other  hand, 
the  sources  of  intoxication  were  as 
much  as  possible  eliminated  by  purga- 
tion and  dietetic  measures  calculated 
to  prevent  the  accumulation  in  the 
blood-stream  of  any  toxic  wastes,  i.e., 
wastes  imperfectly  prepared  for  prompt 
elimination  by  the  kidneys.  J.  Madison 
Taylor  (Monthly  Cyclo.  of  Pract.  Med., 
March,  1909). 

When  epilepsy  is  complicated  by 
bromism  this  may  be  combated  with 


746 


ANIMAL   EXTRACTS    (SAJOUS). 


thyroid  gland.  A  cachet  0.1  Gm. 
(1/^  grains)  of  desiccated  thyroid  is 
given  every  morning  for  three  weeks, 
then  suspended  from  time  to  time  for 
a  fortnight.  Two  doses,  each  of  1 
Gm.  (15  grains)  of  potassium  bro- 
mide, are  given  daily  at  equal  inter- 
vals, say  at  10  a.m.  and  10  p.m.,  apart 
from  meals,  and  dissolved  in  half  a 
wineglassful  or  less  of  water.  The 
bromide  is  to  be  given  regularly  with- 
out suspending  the  treatment.  J.  A. 
Sicard  (Jour,  de  med.  de  Paris,  Nov. 
19,  1910). 

The  writer  emphasizes  the  following 
points :  The  undeniable  relation  of 
epileptic  seizures  to  menstruation. 
Absolute  freedom  from  attacks  in  the 
intervals  between  menstrual  periods. 
Apparently  perfect  integrity  of  the 
ovaries  and  still  occurrence  of  epileptic 
fits  immediately  before  or  during  men- 
struation. The  inability  of  controlling 
the  fits  with  the  usual  bromide  treat- 
ment. The  good  and  even  excellent 
effect  of  thyroid  extract.  The  mode  of 
administration  of  the  latter,  viz.,  thy- 
roid extract  between  the  menstrual 
periods  and  bromides  without  thyroid 
only  a  few  days  before  menstruation. 
Alfred  Gordon  (Penna.  Med.  Jour., 
Feb.,  1910). 

Two  cases  of  cretinism  in  twin 
brothers,  both  of  whom  suffered  in 
addition,  one  from  epileptic  seizures, 
the  other  from  a  marked  degree  of 
ataxia.  The  epileptic  attacks  began  at 
the  age  of  23  and/ rapidly  increased  in 
frequency  until  they  were  of  almost 
daily  occurrence ;  there  were  occasional 
attacks  of  petit  mal  besides  the  seizures 
of  grand  mal.  The  attacks  were  greatly 
modified  by  thyroid  therapy,  although 
this  patient  could  not  tolerate  more 
than  25  grains  of  the  extract  daily. 
The  other  twin,  when  14  years  old, 
developed  a  staggering  gait,  walking 
like  a  drunken  man,  and  suffering 
severe  pains  about  the  hips ;  the  arms 
soon  became  involved  so  that  he  could 
hardly  write.  This  patient  began  by 
taking  15  grains  of  thyroid  extract  a 
day,  and  the  dose  was  increased 
gradually  until  he  was  taking  45  grains 


a  day  without  toxic  manifestations.  All 
his  symptoms  improved,  including  the 
ataxia;  he  is  able  to  walk  (though  with 
a  waddling  movement)  and  to  write, 
earning  his  living  by  typewriting.  L.  S. 
Manson   (Med.  Record,  Jan.  1,  1910). 

Eclampsia. — It  is  now  generally  rec- 
ognized that  this  complication  of  the 
puerperal  state  is  due  to  toxemia.  Thy- 
roid extract  is  indicated,  therefore, 
since  it  enhances  the  destruction  of 
toxic  wastes  and  other  poisons. 

This  accounts,  from  my  viewpoint, 
for  the  fact  that  a  number  of  cases 
have  been  reported  in  which  the  con- 
vulsions ceased  under  the  influence  of 
rather  large  doses  of  thyroid  gland. 
Nicholson  obtained  excellent  results 
with  7^2  grains  of  thyroid  extract  every 
three  or  four  hours,  with  morphine  as 
an  adjunct.  Baldowsky  confirmed  its 
value  in  2  cases ;  in  the  first,  a  multipara 
in  the  seventh  month  of  pregnancy,  a 
convulsion  occurring,  18  grains  of  thy- 
roid extract  were  given.  The  fits 
ceased.  The  thyroid  was  continued  for 
two  days  longer — 10  grains  daily — and 
the  patient  seemed  quite  recovered.  A 
fortnight  later  she  again  developed  se- 
vere eclamptic  fits,  sixteen  seizures  al- 
together, which  were  treated  by  thy- 
roid extract,  with  narcotic  remedies, 
and  recovery  followed.  The  other  was 
a  primipara  at  term  who  was  suddenly 
seized  with  convulsions  at  the  com- 
mencement of  labor.  Thyroid  extract 
alone  was  given,  and  the  attack  ceased 
before  the  rupture  of  the  membranes, 
The  labor  took  place  without  any  un- 
usual symptom,  and  the  puerperium 
was  normal. 

I  have  pointed  out,  however,  that  the 
action  of  the  thyroid  is  greatly  enhanced 
by  the  simultaneous  use  of  hypodermo- 
clysis.  In  some  cases  the  thyroid 
preparation  was  dissolved  in  the  saHne 
solution  injected. 


ANIMAL   EXTRACTS    (SAJOUS). 


747 


Severe  case  in  which,  2  pints  of  saline 
solution  having  been  prepared,  15  tab- 
loids of  extract  of  thyroid  (5  grains 
each,  B.  W.  &  Co.)  were  dissolved  in 
the  saline  and  injected  below  the  breast. 
Within  an  hour  and  a  half  there  was  a 
decided  improvement,  both  in  the  fre- 
quency and  severity  of  the  fits,  and  in 
another  hour  the  bowels  moved  and 
labor  began.  Under  chloroform  the 
labor  was  terminated  with  forceps  with 
as  little  delay  as  possible,  and  on  the 
removal  of  the  placenta  bleeding  was 
freely  encouraged.  The  child  was  dead. 
The  fits  numbered  Z7,  so  far  as  could 
be  counted.  From  this  time  onward  the 
fits  ceased.  She  remained  semicon- 
scious for  forty-eight  hours,  when  she 
developed  a  right  basal  pneumonia, 
with  a  crisis  seven  days  later,  after 
which  she  made  a  rapid  recovery.  The 
urine  was  examined  three  weeks  after- 
ward, and  found  to  contain  only  a 
trace  of  albumin.  J.  C.  G.  Macnab  and 
D.  S.  E.  Macnab  (Jour,  of  Obstet.  and 
Gyn.,  Nov.,  1904). 

Migraine. — This  disorder  is  now 
generally  attributed  to  the  gouty  diath- 
esis, i.e.,  to  the  accumulation  in  the 
blood  of  intermediate  waste  products 
of  the  purin  or  alloxuric  type.  Thy- 
roid preparations,  by  promoting  the 
conversion  of  these  toxic  products  into 
bodies  that  are  readily  eliminated  by  the 
kidneys,  antagonize  this  pathogenic 
process.  But  here,  again,  small  doses 
are  alone  indicated;  1  or  2  grains  (0.6 
to  0.13  Gm.)  of  desiccated  thyroid 
during  meals  suffice  at  first,  the  effect 
being  kept  up  after  a  few  weeks  by  a 
single  grain  daily.  The  free  use  of 
water  as  beverage,  abstention  from  red 
meats,  and  out-of-door  exercise  are 
necessary  accompaniments  to  obtain 
the  best  results. 

Case  of  very  severe  recurrent  mi- 
graine in  which  the  writer  used  thy- 
roid extract  with  success.  The  patient 
was  a  woman  aged  40  years  who 
since  childhood  had  been  subject  to 
gxtremely  severe  hemicranias,  accom- 


panied by  injection  and  irritation  of 
the  conjunctiva  of  the  eye  on  the 
corresponding  side,  a  dilatation  of 
the  pupil,  and  blepharospasm.  The 
attacks  of  migraine  in  this  case  re- 
curred with  great  regularity  about 
every  twenty-eight  days  and  usually 
preceded  the  menstrual  periods.  The 
correspondence  of  the  menstruation 
and  the  migraine  in  this  case  was 
very  complete.  The  woman  had  no 
attacks  of  migraine  during  pregnancy 
and  lactation,  but  developed  the  same 
attacks  after  weaning  her  infant.  At 
the  age  of  36  years,  her  flow  became 
irregular  and  the  attacks  followed  suit. 
It  was  then  that  thyroid  treatment  was 
thought  of.  The  theoretical  basis  for 
this  treatment  in  such  cases  is  that  the 
attacks  of  migraine  are  caused  through 
vasomotor  changes  induced  by  the  cir- 
culation of  certain  toxins  in  the  body, 
which  are  derived  from  an  insufficiency 
in  the  function  of  the  thyroid  gland,  or 
from  a  disturbance  in  the  balance  of 
internal  secretion  between  the  gland 
and  the  ovaries.  Tablets  of  thyroid 
extract"  were,  therefore,  given  to  this 
patient,  with  the  result  that  within  two 
months  not  only  vvas  the  menstrual 
function  restored  to  regularity,  but  the 
attacks  of  migraine  totally  disappeared. 
Consiglio  (Gaz.  degli  Ospedali,  Nov.  20, 
1904). 

Certain  obstinate  forms  of  headache 
are  due  to  thyroid  deficiency.  Such 
patients  may  be  relieved  by  thyroid  tab- 
lets. In  every  migraine  of  unknown 
origin,  inquiry  should  be  made  into  the 
functions  of  the  thyroid  and  for  the 
presence  of  symptoms  of  hypothyroid- 
ism. If  these  signs  are  present,  thyroid 
medication  should  be  resorted  to. 

Thyroid  migraine  does  not  differ  in 
its  signs  from  common  migraine.  It  is 
either  precocious  or  tardy,  hereditary 
or  acquired,  uni-  or  bi-  lateral,  or  it 
may  be  syndromic  or  symptomatic.  It 
may  last  only  some  hours  or  some  days, 
but  it  is  always  paroxysmic.  Cephal- 
algia accompanied  by  vomiting  requires 
rest  and  quiet  in  bed.  It  may  depend 
upon  some  ophthalmic  trouble.  Other 
varieties  of  cephalalgia  are  also  favor- 
ably   influenced    by    thyroid    treatment. 


748 


ANIMAL   EXTRACTS    (SAJOUS). 


Leopold-Levi  and  de  Rothschild 
(Bull,  et  mem.  de  la  Soc.  Med.  des 
Hopitaux  de  Paris,  Maj^  17,  1906). 

Case  of  autointoxication  of  intes- 
tinal origin  manifested  by  violent 
migraine.  When  the  colon  bacilli 
were  isolated  it  was  found  that  S  c.c. 
injected  into  a  rat  killed  it  in  a  few 
hours.  This  is  a  very  marked  degree 
of  virulency,  for  it  is  sometimes  pos- 
sible to  inject  as  high  as  10  c.c.  with- 
out effect.  No  '  treatment  proving 
curative  and  his  skin  being  dry,  he 
was  given  thyroid  gland,  beginning 
with  1  grain,  increased  to  2  three  times 
a  day.  Within  two  weeks  the  symptoms 
all  disappeared.  At  the  end  of  two 
months  the  writer  again  injected  the 
Bacillus  coli  into  a  rat,  and  it  had  lost 
its  virulency.  That  was  a  year  ago,  and 
he  has  had  no  recurrence.  The  writer 
had  another  case  which  presented  this 
marked  symptom  of  dry  skin  and  head- 
ache. This  patient  also  suffered  from 
double  vision.  The  writer  examined 
the  feces  and  found  a  very  high  viru- 
lency of  the  Bacillus  coli.  Began 
treatment  with  the  thyroid  substance, 
and  the  case  showed  that  the  bacilli 
were  no  longer  virulent.  F.  B.  Turck 
(Jour.  Med.  Soc.  of  New  Jersey,  July, 
1911). 

Asthma. — A   certain   proportion   of 
these  cases  is  also,  as  is  well  known,  a 
manifestation   of   the    gouty    diathesis. 
Hence,  the  value  of  thyroid  prepara- 
tions   owing    to    the    antitoxic    action 
which  renders  them  useful  in  migraine. 
A    certain    percentage    of    cases    of 
asthma,    in    particular    those    of    the 
essential   or  "neuroarthritic"  type,  is 
favorably    influenced    by    the    use    of 
thyroid    or    corpus    luteum    prepara- 
tions.    The  experience  of  the  authors 
with  this  mode  of  treatment  amounts 
to  14  cases,  of  which  7  (50  per  cent.) 
were  notably  benefited.    Thyroid  was 
used   in   6   of   these   patients,    corpus 
luteum  in  1. 

The  use  of  thyroid  in  small  doses 
may  cause  improvement  in  certain  cases 
of  pseudoasthma  associated  with  em- 
physema,  certain   instances   of   dyspnea 


of  asthmatic  type  (in  renal  and  gastric 
infections),  or  of  paroxysmal  type  (in 
pulmonary  sclerosis  of  tuberculous 
origin),  as  well  as  in  cases  of  ordinary 
"nasal  asthma,"  or  even  "hay  asthma." 
Leopold-Levi  and  H.  de  Rothschild 
(Bull,  med.,  May  \A,  1910). 

Tetanus. — As  thyroid  preparations 
promptly  arrest  the  tetanus  that  occurs 
after  removal  of  the  thyroid,  they 
suggest  themselves  not  only  as 
prophylactics,  but  also  to  assist  teta- 
nus antitoxin.  The  latter  sometimes 
fails  merely  because  the  spasmogenic 
poisons  are  not  sensitized  or  "opso- 
nized" to  its  effects,  as  shown  by  a  com- 
paratively low  temperature ;  desiccated 
thyroid  in  full  doses  tends  to  correct 
j;his  condition  and  to  increase  the 
chances  of  recovery. 

Osseous  Disorders. — As  far  back  as 
1897  Gabriel  Gauthier  showed  that 
delayed  union  in  fractures  was  coun- 
teracted by  thyroid  preparations,  con- 
solidation occurring  in  some  instances 
as  early  as  the  fifteenth  day.  Similar 
results  have  been  obtained  by  many 
observers,  the  proportion  of  success- 
ful cases  being  about  60  per  cent. 
Removal  of  the  thyroid  had  been 
found  by  Hanan,  Steinlein,  and  Bayon 
to  prevent  the  healing  of  fractures  in 
otherwise  healthy  animals,  thus  af- 
fording a  sound  basis  for  the  use  of 
thyroid  preparations.  Its  beneficial 
effects  are  best  shown  in  the  young, 
its  value  decreasing  as  the  patient  is 
more  advanced. 

The  absence  of  this  gland  materially 
affects  the  normal  healing  of  a  fracture. 
There  is  a  delay  in  the  development  of 
both  the  callus  and  the  following  retro- 
gressive metamorphosis.  For  the  first 
two  weeks  no  difference  microscopically 
could  be  seen,  but  by  three  weeks  the 
fracture  in  the  normal  animal  was  al- 
most completely  ossified,  whereas  in 
the    animal    from    whom    the    thyroid 


ANIMAL  EXTRACTS    (SAJOUS). 


749" 


gland  had  been  removed  the  callus  con- 
sisted almost  entirely  of  pure  cartilage. 
Even  after  eleven  weeks  there  was  still 
some  cartilage  present  around  the  frac- 
ture in  those  animals  which  had  had 
their  thyroids  removed,  but  complete 
ossification  did  finally  take  place.  The 
formation  of  the  new  medullary  canal 
began  during  the  eleventh  week,  but 
was  not  completed  twenty-four  weeks 
after  the  fracture.  The  callus  in  the 
animals  deprived  of  the  thyroid  gland 
is  smaller  than  in  normal  animals  dur- 
ing the  stage  of  development,  but  dur- 
ing the  stages  of  retrograde  metamor- 
phosis it  is  larger  than  normal.  The 
difference  in  the  healing  of  fractures 
between  normal  animals  and  those  de- 
prived of  their  thyroids  is  greater  the 
longer  the  time  since  the  removal  of 
the  gland  to  the  time  of  fracture. 
Steinlein  (Archiv  f.  klin.  Chir.,  Bd.  60, 
H.  2,  1900). 

Thyroid  preparations  have  also  been 
used  with  success  in  osteomalacia, 
rickets,  and  osteomyelitis.  All  these 
beneficial  effects  are  explained  by  the 
influence  of  thyroid  on  metabolism,  all 
functions,  including  the  processes  of 
repair,  being-  enhanced.  The  marked 
influence  of  the  thyroid  over  calcium 
metabolism  shown  by  Parhon,  Macal- 
lum,  and  others  is  another  potent 
factor  in  the  marked  benefit  noted  in 
these  disorders. 

In  S  cases  of  rachitis  the  effects  of 
thyroid  were  marked,  the  children 
rapidly  increasing  in  height  under  the 
influence  of  the  mild  organotherapy, 
and  without  displaying  any  evidence  of 
intolerance.  They  seemed  to  benefit  in 
every  way  by  the  thyroid  treatment,  be- 
coming more  intelligent  and  lively  dur- 
ing the  two  weeks'  and  six  weeks' 
courses  with  an  interval  of  two  months. 
Variot  and  Pironneau  (Bull,  de  la  Soc. 
de  Ped.,  April,  1911). 

Rheumatism,   Chronic  Progressive. 

— Following  the  experience  of  Revil- 
liod,  Lancereaux  has  urged  the  value 
of  thyroid  preparations  in  this  class  of 


disorders  many  years,  but,  as  is  often 
the  case,  the  scoffers  of  the  profession 
have  caused  the  valuable  observations 
of  both  these  distinguished  clinicians 
to  be  ignored,  thus  perpetuating  need- 
lessly the  acute  sufferings  of  the  many 
victims  of  this  disease.  When  its  path- 
ogenesis is  interpreted  from  my  stand- 
point (see  "Internal  Secretions"  Suppl., 
p.  1869,  1907),  i.e.,  "inadequate  catabo- 
lism  of  tissue  wastes  and  excitation  by 
the  toxic  products  formed  of  the  vaso- 
motor center,"  the  favorable  influence 
of  thyroid  preparations  is  self-evident: 
the  toxic  wastes  which  provoke  excess- 
ive vascular  tension  and  pain  being 
more  actively  broken  down,  the  pri- 
mary cause  of  the  disorder  is  removed. 
Souques  (1908),  in  2  cases  of  this  dis- 
ease, found  the  thyroid  gland  atro- 
phied. Many  cases  have  recently  been 
treated  successfully.  Leopold-Levi  and 
de  Rothschild,  who  have  had  the  great- 
est experience  with  this  class  of  cases, 
recommend — in  keeping  with  the  teach- 
ings of  my  own  experience,  and  now 
sustained  by  the  experience  of  many 
other  clinicians — that  small  doses 
should  be  used. 

[As  Rachford  (Phila.  Med.  Jour.,  April 
16,  1898)  observed  nine  years  ago,  "thyroid 
feeding  will  increase  the  excretion  of  the 
alloxuric  bodies  in  the  urine,  and  will  pro- 
duce an  acute  arthritis  in  a  patient  suffering 
from  chronic  rheumatic  gout."  Large  doses 
will  thus  prove  harmful  where  small  doses 
will  prove  beneficial.     C.  E.  de  M.  S.] 

Case  of  a  man  who  had  suffered  for 
thirty-six  years  from  rheumatism  and 
gout,  with  decided  arteriosclerosis, 
high-tension  pulse,  heart  hypertro- 
phied,  and  albuminuria,  who  under 
the  infliuence  of  Baumann's  iodothy- 
rin,  started  with  ^  Gm.  daily — in- 
creasing %  Gm. — was  relieved  of  the 
pain  in  the  limbs,  polyuria  and  albu- 
minuria controlled,  the  heart  im- 
proved, tension  of  the  pulse  lessened, 
although  it  was  more  rapid.     Lance- 


750 


ANIMAL   EXTRACTS    (SAJOUS). 


reaux     and     Paulesco     (Bulletin     de 
I'Acad.  de  Med.,  Jan.  3,  1899). 

In  acute  rheumatic  fever  there  are 
usually  swelling  and  tenderness  of  the 
thyroid,  usually  running  parallel  with 
the  general  disease,  and  experience  has 
shown  that  if  the  swelling  and  tender- 
ness of  the  thyroid  diminishes  without 
a  similar  improvement  in  the  general 
condition  the  attack  is  likely  to  be  an 
obstinate  one,  and  if  the  thyroid  symp- 
toms fail  to  appear  at  all  treatment  is 
likely  to  be  unsatisfactory,  while  a 
parallelism  between  thyroid  involve- 
ment and  the  joint  disease  suggests  a 
favorable  prognosis.  The  thyroid  secre- 
tion is  antibacterial  in  action  and  sup- 
ports the  organism  in  its  effort  to 
overcome  the  disease.  The  direct  action 
of  the  iodine  preparations  on  the  thy- 
roid may  explain  their  therapeutic  value 
in  the  treatment  of  rheumatism.  Vin- 
cent (Bull,  et  mem.  de  la  Soc.  Med. 
des  Hop.,  No.  14,  1907). 

Case  of  a  young  woman  28  years  of 
age  who  was  being  treated  by  X-rays 
for  hypertrichosis  of  the  chin.  She  was 
free  from  any  known  hereditary  influ- 
ence. After  the  second  seance  she 
noted  pains  in  the  ankles  and  toes ; 
after  the  eighteenth  seance  of  the 
Roentgen  rays  the  rheumatic  manifes- 
tations extended  to  the  right  knee  and 
to  the  hands.  At  the  same  time  her 
face  became  puffy  in  appearance,  and 
she  became  physically  and  mentally 
apathetic.  On  examination  painful 
tumefaction  of  the  ankles  and  toes  was 
found,  and  very  marked  swellings  of 
the  joints  of  the  right  hand  and  fingers, 
accompanied  by  edemar,  were  present. 
The  visceral  functions  were  normal,  al- 
though there  were  dyspeptic  disturb- 
ances and  menstruation  was  excessive. 
The  thyroid  gland  was  found  to  be 
markedly  diminished  in  volume. 

The  ordinary  antirheumatic  treatment 
proved  of  no  value,  and,  struck  by  the 
thyroid  alterations,  the  mental  change, 
the  puffiness,  etc.,  the  author  was  led 
to  the  use  of  thyroid  medication.  Two- 
grain  tablets  of  the  desiccated  gland 
were  first  employed.  Four  days  after 
thyroid  medication  was  begun  the  artic- 
ular pains   ceased,    the    swellings   went 


down,  and  in  three  weeks  the  patient 
was  able  to  take  up  her  ordinary  occu- 
pations. M.  Acchiote  (Gazette  Med. 
d'Orient,  May,  1907). 

Report  of  39  cases  of  chronic  rheu- 
matism during  the  last  three  years  in 
which  treatment  was  with  desiccated 
and  pulverized  sheep  thyroids;  from 
1  to  3  doses  a  day  of  10  eg.  each, 
equivalent  to  SO  eg.  of  fresh  glands, 
were  given.  The  patients'  ages  ranged 
from  12  to  75  years,  and  in  5  cases  the 
deformity  resulting  from  the  rheuma- 
tism had  confined  the  patients  to  bed 
for  years.  In  9  other  cases  the  per- 
sistence of  the  pains,  recurrence  of  sub- 
acute attacks,  and  deformities  were  very 
distressing.  In  19  grave  or  severe 
cases,  2  of  the  patients  can  now  be  re- 
garded as  clinically  cured  under  the 
treatment,  and  in  14  cases  there  was 
great  improvement  either  in  the  pain, 
the  functional  impotence  or  the  de- 
formity in  the  joints  or  elsewhere.  In 
20  moderate  or  mild  cases  of  chronic 
rheumatism,  18  of  the  patients  were 
immeasurably  improved  or  cured.  The 
results  were  better  the  more  recent  and 
milder  the  cases.  The  benefit  has  per- 
sisted in  the  various  cases.  Leopold- 
Levi  and  de  Rothschild  (Bull,  de 
I'Acad.  de  Med.,  March  10,  1908). 

Uterine  Disorders.  —  Various  con- 
ditions of  the  genital  apparatus,  such 
as  the  onset  of  puberty,  pregnancy, 
fibroid  tumor,  which  cause  a  distinct 
change  in  the  metaboHsm  of  the  entire 
organism,  frequently  produce  enlarge- 
ment of  the  thyroid  gland.  Again, 
the  deficiency  of  the  normal  thyroid 
secretion  following  thyroidectomy  in 
myxedema,  cretinism,  etc.,  is  often 
associated  with  atrophic  changes  in 
the  genital  apparatus,  as  shown  by 
Fisher,  of  Vienna. 

This  clearly  indicates  direct  associa- 
tion between  the  thyroid  and  the  genital 
system,  and  has  suggested  the  use  of 
thyroid  preparations.  The  vomiting  of 
pregnancy  is  also  benefited  by  their 
use. 


ANIMAL   EXTRACTS    (SAJOUS). 


751 


Five  cases  of  pernicious  nausea  of 
pregnancy  in  which  the  writer  has  had 
good   results   hy   the    administration   of 
thyroidin.      Four    of    these    cases    were 
under    his    immediate    observation,    and 
1    was    treated    by    a    colleague.      The 
remedy    is    administered    several    hours 
before  the  time  when  the  worst  parox- 
ysms of  vomiting  appear.    The  stomach 
must  be   absolutely   empty   at  the   time 
of    the    administration.      It    is    usually 
best  to  give  it  in  the  early  morning  be- 
fore the  patient  leaves  her  bed.     She  is 
encouraged  to   sleep   afterward  and  to 
take    nourishment    before    getting    up. 
From  an  hour  to  half  an  hour,  however, 
before  the  other  meals  of  the  day,  the 
remedy  should  be  used,  and  also  before 
going  to  bed.    The  morning  dose  should 
be  the  largest,  6  decigrams  being  given 
in  some  cases.     If  the  patient  vomits  in 
the   evening,   a   similar   dose   should  be 
given  before  this  time.     The  remedy  is 
best    used    in    powder,    and    sometimes 
sodium  bicarbonate  or  bismuth  may  be 
combined   with   it  to   advantage.      Sieg- 
mund     (Zentralbl.     f.    Gynak.,  Nu.    42, 
1910). 
They  have  been  found  of  value  for 
the  purpose  of  arresting  hemorrhage, 
whether  this  occur  in  connection  with 
abortion,  tumors,  or  uterine  malposi- 
tions.    A  remarkable  case  of  metror- 
rhagia due  to  hemophilia  successfully 
treated   with    thyroid   extract    was    re- 
ported by  Dejace.     In  the  disorders 
of  menopause,  hemorrhages,  flushes, 
irritability,     migraine,    etc.,     thyroid 
preparations    are    of    undoubted    value 
owing  to  their  ability  to  promote  the 
destruction   of    waste    products,    which 
underlie  these  morbid  phenomena. 

It  is  very  probable  that  the  toxemia 
of  pregnancy  is  largely  dependent  upon 
faulty  metabolism ;  at  least,  an  insuffi- 
cient metabolism  is  an  accompaniment 
which  greatly  adds  to  the  seriousness 
of  the  condition.  Failure  of  the  thyroid 
gland  to  hypertrophy  during  pregnancy 
is  probably  followed  by  insufficient  me- 
tabolism, and  may  result  in  the  various 
forms  of  toxemia  of  pregnancy.    When 


there  is  a  failure  of  the  normal  hyper- 
trophy of  the  thyroid  gland  durmg 
pregnancy  and  when  there  is  a  diseased 
thyroid,  as  in  Graves's  disease,  the  ad- 
ministration of  thyroid  substance,  by 
supplying  the  deficiency  of  the  normal 
thyroid  secretion  and  by  diuretic  action, 
may  materially  improve  a  faulty  metab- 
olism and  thus  give  a  lavorable  in- 
fluence upon  the  manifestations  of  the 
toxemia  of  pregnancy.  Ward  (Surg., 
Gynec,   and   Obstet,   Dec,   1909). 

S  u  m  m  a  r  y. — Thyroid  preparations 
have  been  used  and  recommended  in 
many  -other  diseases,  but  the  fore- 
going seem  to  me  to  represent  those 
in  which  they  are  productive  of  real 
good.  My  own  experience  has  sug- 
gested that  this  would  prove  true, 
particularly  as  to  desiccated  thy- 
roid : — 

1.  In  diseases  due  to  slowed  de- 
struction of  toxic  wastes,  as  shown 
by  its  action  in  tetany,  epilepsy, 
eclampsia,,  disorders  of  menopause, 
asthma,  chronic  rheumatism,  mi- 
graine, and  also  by  those  due  to  slow 
oxidation  of  fats,  as  in  obesity  and 
Dercum's  disease:  adiposis  dolorosa. 

2.  In  diseases  due  to  lowered  gen- 
eral nutrition  of  all  tissues,  including 
the  bones,  as  shown  by  its  action  in 
cretinism,  myxedema,  and  kindred 
disorders — osteomalacia,  rickets,  and 
osteomyelitis. 

3.  In  disorders  due  to  lowered  nutri- 
tion of  the  muscular  elements,  including 
the  skeletal  and  vascular  muscles,  as 
shown  by  its  action  in  general  adyna- 
mia, neurasthenia,  and  myasthenia. 

4.  In  all  cases  in  which  the  processes 
of  repair  or  absorption  are  deficient,  as 
shown  by  its  action  in  delayed  union 
of  fractures,  certain  benign  and  ma- 
lignant neoplasms,  and  syphilitic  tis- 
sue and  bone  necrosis. 

5.  In  infectious  diseases — owing  to 
the    increase   of    autoantitoxin,    thyro- 


752 


ANIMAL   EXTRACTS    (SAJOUS). 


iodase  (opsonin),  and  phagocytes — as 
shown  by  its  action  in  tuberculosis, 
typhoid  fever,  infectious  tonsillitis, 
certain  exanthemata,  and,  in  general, 
infections  in  which  fever  is  a  prom- 
inent symptom. 

PARATHYROID  ORGAN- 
OTHERAPY. 

The  two  internal  of  these  four  small 
glandules  were  described,  as  previously 
stated,  by  Sandstrom  in  1880,  while  the 
two  external  were  discovered  by  Nich- 
olas in  1893,  and  also  in  1895  by  Kohn. 
Though  distinct  from  the  thyroid 
gland,  they  are  in  close  apposition  to, 
and  sometimes  imbedded  in,  this  organ, 
and  are  supplied  mainly  by  the  inferior 
thyroid  artery.  Though  histologically 
different  from  the  thyroid  gland,-  they 
also  contain  a  colloid  substance  in 
which  iodine  occurs  in  relatively  large 
proportion.  That  they  carry  on  some 
general  function  is  shown  by  the  fact 
that  their  removal  causes  tetany,  while 
removal  of  the  thyroid  divested  of  its 
parathyroids  causes  myxedema,  arrests 
growth,  and  impairs  calcium  metabo- 
lism, the  bones,  including  the  teeth,  be- 
coming soft  and  brittle. 

When  the  extirpation  of  all  the  para- 
thyroid glands  is  complete,  tetany  ap- 
pears, even  in  herbivora.  Failure  to 
produce  tetany  experimentally  is  prob- 
ably due  to  the  fact  that  some  para- 
thyroid tissue  remains.  Only  a  very 
small  amount  of  parathyroid  tissue  is 
reciuired  to  prevent  tetany.  The  ex- 
periments of  the  virriters  suggest  that 
calcium  salts  have  a  moderating  influ- 
ence upon  the  nerve-cells.  The  para- 
thyroid secretion  in  some  way  controls 
the  calcium  exchange  in  the  body.  In 
tetany  there  is  a  marked  reduction  in 
a  calcium  content  of  the  tissues  and  an 
increased  output  in  the  urine  and  feces. 
The  injection  of  a  solution  of  a  salt 
of  calcium  into  the  circulation  of  an 
animal  in  tetany  promptly  checks  all 
the  symptoms;  the  injection  of  sodium 


or  potassium  salts  tends  to  intensify 
the  symptoms.  The  effect  of  mag- 
nesium salts  is  marked  by  its  toxic 
action.  The  relief  by  calcium  is  tem- 
porary. The  same  relief  is  obtained 
by  the  injection  of  an  emulsion  of  para- 
thyroid glands.  Often  the  temporary 
relief  is  sufficient,  as  the  remnants  of 
parathyroid  tissue  may  recover  their 
function.  MacCallum  and  Voegtlin 
(Jour,  of  Exper.  Med.,  Jan.  9,  1909). 

Experiments  upon  animals  have  sug- 
gested that  the  parathyroids  play  an  in- 
disputable role  in  osteogenesis ;  that 
their  action  is  equally  distinct  in  the 
growth  of  healthy  bone,  and  the  cica- 
trization of  fractured  bone;  that  their 
action,  which  is  certain  on  the  young 
organism,  seems  to  be  nil  upon  adults ; 
that  all  or  part  of  the  role  in  osteo- 
genesis attributed  to  the  thyroid  should 
be  assigned  to  the  parathyroids,  and 
that  it  would  be  important  to  make  a 
trial  in  man  of  the  accelerating  action 
of  parathyroid  medication  in  the  con- 
solidation  of  fractures  in  the  young. 
Morel  (Archiv  gen.  d.  chir.,  vol.  vi,  p. 
231,  1910). 

Confirmation  of  the  relationship 
between  the  parathyroids  and  calcium 
metabolism.  In  rodents  the  incisor 
teeth  undergo  constant  growth.  Dur- 
ing experiments  on  the  relationship 
between  parathyroid  extirpation  and 
tetany,  the  writer  noticed  that  the 
incisor  teeth  of  the  rats  became  re- 
peatedly fractured.  He  found  that  in 
the  normal  incisor  tooth  of  this 
animal  the  dentin  forms  the  prin- 
cipal portion;  a  conical  pulp  cavity 
pierces  this  longitudinally,  and  a  nar- 
row zone  of  dentin ,  adjoining  this 
cavity  normally  undergoes  calcifica- 
tion, while  the  greater  part  has  al- 
ready received  its  complete  deposit 
of  calcium.  On  removal  of  the  para- 
thyroids, it  was  found  that  calcifica- 
tion of  the  dentin  at  once  ceased 
more  or  less  completely;  the  por- 
tion already  hardened  underwent  no 
change,  but  as  the  effects  of  use  wore 
down  this  older  part  the  new  uncal- 
cified  dentin  taking  its  place  lacked 
strength,      and      fractures      followed. 


ANIMAL   EXTRACTS    (SAJOUS). 


753 


Imperfections  in  tlie  enamel  deposit 
also  occurred,  though  at  a  later  period 
than  the  alterations  in  the  dentin. 
By  regulating  the  time  between  ex- 
tirpation of  the  glands  and  examina- 
tion of  the  tooth,  all  transitional 
stages  between  the  normal  tooth  and 
one  almost  completely  decalcified 
could  be  obtained. 

Again,  transplantation  of  the  para- 
thyroids from  the  neck  to  the  abdom- 
inal wall  was  successfully  accom- 
plished in  9  cases.  In  each  instance 
there  was  found  in  the  incisor  teeth 
a  zone  of  uncalcified  dentin,  corre- 
sponding to  the  period  of  parathyroid 
quiescence,  interposed  between  two 
layers  of  normal  dentin.  This  dem- 
onstrates clearly  the  influence  of  the 
parathyroids  on  calcium  metabolism. 
Erdheim  (Zeitsch.  f.  Pathol.,  Bd.  vii, 
S.  178,  1911). 

The  functions  of  the  parathyroids 
are  still  in  doubt;  some  investigators 
claim  that  they  have  no  independent 
function;  others  that  they  govern  cal- 
cium metabolism  independently  of  the 
thyroid.  A  third  group,  to  which  my 
own  researches  have  caused  me  to  be- 
long, believe  that  they  supply  a  secretion 
which  combines  with  that  of  the  thyroid 
to  carry  on  the  functions  of  the  latter, 
i.e.,  to  sustain  tissue  and  calcium  metab- 
olism besides  carrying  on  their  anti- 
toxic functions.  From  my  viewpoint, 
their  secretion  plays  the  principal 
role  in  the  formation  of  Wright's  op- 
sonin in  conjunction  with  the  thy- 
roid, as  shown  under  the  preceding 
heading. 

[The  investigations  of  King,  Biondi  (Berl. 
klin.  Woch.,  XXV,  p.  954,  1888),  Zielinska 
(Virchow's  Archiv,  cxxxvi,  p.  170,  1894), 
Vassale  and  de  Brazza  (Arch.  ital.  di  biol- 
ogia,  xxiii,  p.  292,  1895)  on  the  thyroid,  and 
those  of  Welsh  (Jour,  of  Anat.  and  Physiol., 
April,  1898),  and  Capobianco  and  Mazziato 
(Giorn.  Int.  de  Scienze,  Nos.  8,  9,  and  10, 
1899),  and  others  on  the  parathyroids,  have 
shown  that  the  product  of  these  organs 
passes  into  perivascular  lymph-spaces.    Being 


then  transferred  to  the  larger  cervical  lym- 
phatics, they  are  discharged  by  the  right  and 
left  lymphatic  ducts — the  thoracic  duct,  ac- 
cording to  Pembrey  (Hill's  "Recent  Ad- 
vances in  Physiology,"  p.  579) — into  the  sub- 
clavian veins,  and  by  way  of  the  superior 
vena  cava  to  the  heart.  Here  they  become 
merged  with  the  venous  blood  of  the  entire 
organism,  forming  a  single  secretion — in 
accord  with  Gley's  (La  Presse  medicale, 
January  12,  1898)  view — which  is  then  in- 
evitably carried  to  the  heart,  and  thence  to 
the  lungs.  As  the  venous  blood  carrying  the 
secretion  passes  to  these  organs  to  be  oxy- 
genized, the  secretion  itself  is  likewise  car- 
ried to  the  air-cells. 

The  purpose  of  this  itinerary  suggests 
itself  when  we  recall  that,  as  stated  by  Noth- 
nagel  and  Rossbach  (Therapeutique,  p.  261, 
1889),  hemoglobin  can  fix  large  quantities  of 
iodine.  It  accounts  also  for  the  fact  that 
Gley  (La  Semaine  medicale.  May  25,  1898) 
and  Bourcet  found  iodine  in  the  red  corpus- 
cles. Being  a  component  of  the  albuminous 
hemoglobin  of  these  cells  with  adrenoxidase, 
however,  iodine  should  be  found  in  all  tis- 
sues. While  Bourcet  (cited  by  Morat  and 
Doyon,  Traite  de  physiologic,  vol.  i,  p.  470, 
1904)  ascertained  that  such  was  the  case, 
Justus  (Virchow's  Archiv,  clxxvi,  p.  1,  1904) 
found  it  in  all  cellular  nuclei.  This  latter 
feature  is  important,  since,  as  we  have  seen, 
iodine  serves  to  increase  the  inflammability, 
as  it  were,  of  the  phosphorus  which  all  nuclei 
contain.     C.  E.  de  M.  S.] 

THERAPEUTICS.— The  actual 
value  of  parathyroid  in  therapeutics 
has  not  as  yet  been  clearly  deter- 
mined. It  has  been  tried  with  benefit 
in  postoperative  tetany  by  several 
clinicians.  MacCallum  found  large 
quantities  injected  intravenously  nec- 
essary. Vassale,  James,  and  Halsted 
have  also  had  favorable  results.  While 
Birch  found  thyroid  ineffectual,  para- 
thyroid caused  recovery. 

The  nucleoproteid  of  the  parathyroid 
relieves  the  symptoms  of  acute  tetany 
in  dogs,  but  the  globulin  has  no  such 
power.  Boiling  or  heating  the  nucleo- 
proteid solution  at  80°  C.  for  half  an 
hour   destroys   its   activity,   and   it   de- 


1—48 


754 


ANIMAL   EXTRACTS    (SAJOUS). 


teriorates  rapidly  when  kept  in  solution 
or  frozen.  The  nucleoproteid  relieves 
tetany  by  the  mouth,  but  more  effect- 
ively when  given  subcutaneously  or 
intraperitoneally.  Berkeley  and  Beebe 
(Jour.  Med.   Research,   Feb.,   1909). 

Three  cases  found  in  literature  and  1 
personal  case  in  which  the  transplanta- 
tion of  human  parathyroids  was  fol- 
lowed by  recovery.  Danielson  (Beit- 
rage  z.  klin.  Chir.,  Bd.  xxxvii,  S.  998, 
1910). 

In  postoperative  parathyroid  tetany 

— which  is  prevented  by  removing 
only,  as  does  Kocher,  the  central  part 
of  the  thyroid,  thus  leaving  intact  the 
posterior  capsule,  to  which  the  para- 
thyroids adhere — tlie  spasms  may  be 
arrested  by  implanting  human  thyroids 
from  persons  who  have  just  died  of 
some  non-infectious  disease.  Implanted 
glands  do  not  act  at  once ;  it  is  only 
when  they  assume  their  normal  func- 
tions in  situ  that  recovery  occurs. 

Study  undertaken  with  a  view  to 
determine  the  course  to  be  pursued  by 
the  surgeon  when  a  parathyroid  gland 
has  been  accidentally  removed  or  de- 
prived of  its  blood  supply,  and  in  the 
hope  that  it  might  be  attended  with 
such  success  as  to  justify  the  attempt 
to  transplant  this  glandule  from  man 
to  man.  The  transplantations  were 
made  either  into  the  thyroid,  the  spleen, 
or  in  or  behind  the  rectus  muscle  of 
the  abdomen,  and  were  both  auto-  and 
iso-  transplantations.  The  writer's  de- 
ductions v/ere  as   follows : — 

1.  The  autotransplantation  of  para- 
thyroid glandules  into  the  thyroid  gland 
and  behind  the  musculus  rectus  ab- 
dominis has  been  successful  in  61  per 
cent,  of  the  cases  in  which  a  deficiency 
greater  than  one-half  has  been  created. 

2.  In  no  instance  has  the  autotrans- 
plantation succeeded  without  the  cre- 
ation of  such  a  deficiency. 

3.  Isotransplantation  has  been  uni- 
formly unsuccessful. 

4.  Parathyroid  tissue  transplanted  in 
excess  of  what  is  urgently  required  by 
the  organism  has  not  lived. 


5.  One  parathyroid  autograft  may- 
suffice  to  maintain  the  animal  in  good 
health  and  spirits  for  many  months  and 
possibly  for  years. 

6.  Excised  or  deprived  of  their  blood 
supply  in  the  course  of  operation  upon 
the  human  subject,  parathyroid  glands 
should,  in  the  present  state  of  our 
knowledge,  be  grafted,  and  probably 
into  the  thyroid  gland. 

7.  Complete  excision  of  the  .thyroid 
lobes  in  dogs  may  be  well  borne  for  a 
year  or  more.  The  myxedema,  which 
usually  has  manifested  itself  within  a 
few  weeks,  has  not  increased  after  the 
first  few  months.  May  it  subsequently 
diminish  with  the  hypertrophy  of  ac- 
cessory thyroids? 

8.  Parathyroid  tissue  is  essential  to 
the  life  of  dogs,  as  has  been  conclu- 
sively proven  by  the  result  of  excision 
of  the  sole  sustaining  graft.  W.  S. 
Halsted  (Jour,  of  Exper.  Med.,  vol.  xi, 
No.  1,  1909). 

The  indifference  of  some  surgeons  in 
respect  to  the  importance  of  these  para- 
thyroids merits  severe  criticism.  Per- 
sonal case  which,  their  advice  being 
followed,  developed  very  severe  tet- 
any. The  case  was  saved,  only  after 
all  other  measures  had  been  tried  in 
vain,  by  the  implantation  of  a  thyroid, 
with  its  parathyroids,  obtained  from 
a  small  monkey  and,  one  month  later, 
of  3  parathyroids  and  a  piece  of  thy- 
roid the  size  of  a  small  walnut,  all 
obtained  one-half  hour  after  death 
from  the  body  of  a  man  who  had 
died  of  Bright's  disease  and  uremia. 
These  tissues,  placed  at  once  in  nor- 
mal saline  solution  at  32°  F.  (0°  C), 
were  implanted  successfully  within  an 
hour,  the  simian  thyroid  beneath  the 
patient's  sternomastoid,  and  the  hu- 
man thyroid  and  parathyroid  beneath 
her  left  rectus  abdominis,  under  chlo- 
roform anesthesia.  W.  H.  Brown 
(Annals  of  Surg.,  March,  1911). 

An  emulsion  of  fresh  parathyroids 
may  also  arrest  the  spasms,  but  obvi- 
ously only  as  long  as  the  injected  emul- 
sion is  active.  It  is  administered  in 
saline  solution  subcutaneously.    It  may 


ANIMAL   EXTRACTS    (SAJOtlS). 


^'SS 


prove  curative,  as  in  the  case  cited  be- 
low, but  here  the  parathyroids  were 
onlv  partly  removed,  the  recovery  be- 
ing eventually  due  to  the  resumption  of 
function  by  the  latter. 

Case  treated  successfully  by  means  of 
an  emulsion  of  parathyroids  given  sub- 
cutaneously.     Five   fresh  beef  parathy- 
roids were  placed  in  a  1 :  1000  solution 
of   bichloride   of   mercury   and    allowed 
to  soak  about  ten  minutes.     The  glands 
were    cut,    under    strict    asepsis,    into    5 
pieces  imder  physiological  salt  solution. 
These  pieces  were   placed  in  a  mortar 
and  ground  into  a  homogeneous  mass, 
400   c.c.    of    sterile    salt    solution    being 
poured  into  the  mortar.     This  was  then 
filtered   and    given    as    salt   transfusion 
into  the  patient's  breast.     The  oral  use 
of  thyroid  and  parathyroid  extract  and 
the    feeding    of    raw    parathyroids    had 
proved  entirely  useless.     Only   1   para- 
thyroid had  been  entirely  removed,  and 
the  3  others  only  partly  so.     Branham 
(Amer.  Jour.   Med.   Sci.,  vol.  xlviii,  p. 
161,   1908). 
[In    this    case    the     injured    parathyroids 
recovered  and  resumed  their  functions.     The 
emulsion  only  served,  therefore,  to  compen- 
sate for  the  temporary  absence  of  secretion 
following  the  partial  destruction  of  the  three 
parathyroids    and    did    not    itself    bring    on 
recovery.     C.  E.  de  M.  S.] 

Meat  should  not  be  given  to  such 
cases,  since  it  increases  the  tetany.  The 
diet  should  be  limited  to  milk,  farina- 
ceous foods,  and  fruit.  Exercise  is 
harmful  by  promoting  the  formation  of 
spasmogenic  waste  products.  Rest  in 
bed  or  in  an  armchair  tends  to  reduce 
the  frequency  and  violence  of  the 
spasms, 

Vassale  claims  that  the  parathyroid 
extract  relieves  eclampsia  as  certainly 
as  thyroid  does  myxedema,  while 
Berkeley  tried  it  with  some  degree  of 
success  in  paralysis  agitans.  The  lat- 
ter gives  5  to  8  glands  per  day,  minced 
and  eaten  in  a  bread-and-butter  sand- 
wich. 


The  writer  has  treated  in  consulta- 
tion and  in  his  own  practice  60  cases 
of  paralysis  agitans  with  parathyroid. 
Of  these  between  60  and  65  per  cent, 
who  have  given  the  remedy  a  fair  trial 
have  spoken  favorably  of  it  and  have 
continued  the  treatment.  More  than  a 
dozen  who  began  three  or  four  years 
ago  have  greatly  improved  and  are 
now  only  uncomfortable  when  they  are 
without  the  medicine.  The  writer 
concludes  that  with  such  a  percentage 
of  benefited  cases  as  this  there  seems 
no  longer  any  reasonable  doubt  of  the 
etiological  relation  between  the  disease 
and  the  remedy.  One  or  2  cases  in  the 
hands  of  medical  friends  or  correspond- 
ents appear  to  be  almost  cured,  though 
of  such  a  disease  in  a  patient  of  ad- 
vancing years  a  "cure"  is  always  to  be 
spoken  of  with  reserve.  Berkeley 
(Med.  Record,  Dec.  24,  1910). 

Simonine  also  speaks  of  encourag- 
ing results  in  Sydenham's  chorea  (5 
cures),  but  the  remedy  has  been  tried 
by  too  few  'observers  to  warrant  a  con- 
clusion as  to  its  actual  value. 

ADRENAL  OR  SUPRARENAL 
ORGANOTHERAPY. 

Brown-Sequard  showed  in  1856  that 
death  followed  removal  of  both  adre- 
nals in  from  a  few  hours  to  three  da3^s 
after  a  series  of  general  phenomena 
corresponding  to  those  of  Addison's 
disease,  viz.,  steady  decline  of  the  blood- 
pressure,  intense  prostration,  and  mus- 
cular weakness.  This  observation  was 
not  only  confirmed  by  many  other  in- 
vestigators, but  Oliver  and  Schafer, 
Szymonowicz,  and  Cybulski  showed 
that  adrenal  extract  caused  a  marked, 
though  ephemeral  rise  of  the  blood- 
pressure  and  increased  the  power  of 
the  cardiac  contractions.  This  was  at- 
tributed to  a  direct  action  on  the  mus- 
cular elements  of  the  arterioles  and  on 
the  cardiac  muscle,  accompanied  prob- 
ably by  excitation  of  the  vasomotor 
center.  The  pulse-  and  heart-  beats  are 


756 


ANIMAL   EXTRACTS    (SAJOUS). 


slowed,  but  strengthened.  Gerhardt  as- 
cribes these  phenomena  to  the  rise  of 
blood-pressure,  Ambert  to  stimulation 
of  the  inhibitory  center  because  divi- 
sion of  the  vagi  arrests  them.  They 
are  produced  by  a  minute  dose  of  the 
active  principle  when  it  is  administered 
intravenously,  but  much  larger  doses 
have  no  effect  when  given  by  mouth  or 
subcutaneously.  Blum  and  others  have 
found  that  adrenal  extractives  cause 
glycosuria,  while  Josue  has  shown 
that  they  provoke  arteriosclerosis,  an 
observation  confirmed  by  many  investi- 
gators. 

The  action  of  adrenal  preparations 
is  exercised  upon  involuntary  muscles 
— those  of  the  vessels,  heart,  intestines, 
and  uterus,  for  example.  But,  accord- 
ing to  the  prevailing  view,  this  action 
may  be  antagonistic;  it  may  cause  con- 
traction of  the  intestinal  vessels,  for  in- 
stance, but  relax  the  muscular  coats  of 
the  intestines.  This  has  been  ascribed 
by  some  to  a  direct  action  on  the  nerve- 
terminals;  by  others  to  a  chemical  ac- 
tion on  the  muscular  elements.  The 
secretory  activity  of  the  lachrymal  and 
salivary  glands  is  enhanced. 

PHYSIOLOGICAL  ACTION.— 
All  these  phenomena  having  remained 
unexplained,  personal  researches  and  a 
large  number  of  experimental  and  clin- 
ical facts  found  in  literature  led  me  to 
the  conclusion  in  1903  that  the  physio- 
logical function  of  the  adrenal  secretion 
was  (1)  to  take  up  the  oxygen  of  the 
air  in  the  pulmonary  alveoli  and  carry 
this  gas  to  the  tissues  as  a  constituent 
of  the  oxyhemoglobin,  and  (2)  that  it 
was  the  adrenal  secretion  which,  as  far 
as  the  role  of  oxygen  in  these  processes 
is  concerned,  sustained  oxidation  and 
metabolism. 

[Referring  the  reader  to  the  article  on 
"Adrenals,  Diseases  of,"  in  this  volume  and 


to  my  work  on  the  "Internal  Secretions  and 
the  Principles  of  Medicine,"  the  main  fac- 
tors determined  by  my  investigations  were 
briefly:  (1)  that  the  secretion  of  the  adre- 
nals has  a  marked  affinity  for  oxygen,  and 
that,  owing  to  its  passage  into  the  inferior 
vena  cava,  it  is  inevitably  carried  to  the  pul- 
monary air-cells ;  (2)  that  once  here  it  ab- 
sorbs oxygen— thus  fulfilling  the  role  of  a 
secretion  deemed  necessary  by  various  physi- 
ologists (Paul  Bert,  Miiller,  Bohr,  Haldane 
and  Lorrain  Smith,  and  others)  to  account 
for  pulmonary  respiration;  (3)  that  it  be- 
comes, also  in  this  location,  the  albuminous 
(96  per  cent.)  constituent  of  hemoglobin  and 
the  red  corpuscles,  the  identity  and  source  of 
which  physiologists  have  failed  to  identify, 
and  (4)  that  this  albuminous  constituent  of 
the  hemoglobin  which  I  have  termed  "adre- 
noxidase"  owing  to  its  source,  the  adrenals, 
and  to  its  identity  as  oxidase,  is  distributed 
by  the  red  corpuscles  to  all  parts  of  the 
body  as  an  oxidizing  substance.  C.  E. 
DE  M.  S.] 

This  interpretation  explains  the  phe- 
nomena that  attend  the  use  of  adrenal 
extracts,  adrenalin,  etc.,  in  therapeutic 
doses.  The  rise  of  temperature  noted 
by  Morel,  Lepine  and  the  concomitant 
rise  of  temperature  and  increased  me- 
tabolism noted  by  Oliver  and  Sclia- 
fer  are  due  to  increased  oxidation.  It 
accounts  also  for  the  rise  of  blood- 
pressure,  since  increased  metabolic  ac- 
tivity— excited  directly  by  the  adrenal 
principle  besides  that  due  to  general 
oxidation — of  the  muscular  coats  of 
vessels  is  manifested  by  contraction, 
and,  therefore,  by  elevation  of  the 
blood-pressure.  The  increased  power 
of  the  heart  is  the  obvious  outcome  of 
increased  metabolism  in  the  myocar- 
dium, precisely  as  it  is  in  the  vascular 
muscles,  while  the  slowing  of  its  ac- 
tion is  due  to  the  greater  diastolic  ex- 
pansion that  attends  increased  func- 
tional vigor  and  the  greater  resistance 
the  blood-column  offers  as  a  result  of 
the  increased  blood-pressure. 


ANIMAL   EXTRACTS    (SAJOUS). 


757 


The  same  process  explains  the  phe- 
nomena produced  by  adrenal  extract- 
ives which  appear  quite  discordant 
from  its  more  familiar  efifects  on  the 
blood-pressure,  the  heart,  etc.  They 
produce  arteriosclerosis  by  causing  ex- 
cessive contraction  of  the  vasa  vaso- 
rum,  from  which  the  arterioles  receive 
their  blood.  The  walls  of  the  arteries 
these  minute  vessels  nourish  being 
partly  or  completely  deprived  of  blood, 
they  degenerate,  and  sclerosis  follows. 
Glycosuria  is  also  the  result  of  excess- 
ive metabolism;  the  pancreas,  as  are 
all  other  organs,  being  rendered  over- 
active, its  ferments  are  secreted  in  ex- 
cess. Amylopsin  being  one  of  these, 
the  hepatic  glycogen  is  converted  into 
sugar  in  quantities  exceeding  the  needs 
of  the  tissues,  and  the  unused  sugar  is 
eliminated  by  the  kidneys.  Increased 
metabolism  likewise  explains  the  ab- 
norm.al  activity  of  the  lachrymal  and 
salivary  glands. 

Finally,  the  antagonistic  effects  of 
these  agents  are  accounted  for  by  the 
fact  that,  while  the  intestinal  vessels 
are  contracted  through  the  excessive 
metabolic  activity  produced  in  their 
muscular  coats,  the  intestines  them- 
selves are  relaxed  because  the  volume 
of  blood  supplied  to  them  is  reduced  by 
the  undue  constriction  of  their  vessels. 

[The  participation  of  the  adrenal  secretion 
in  this  phenomenon  is  shown  by  the  fact 
that  the  supposed  inhibitory  action  of  the 
sympathetic  on  intestinal  movements  (which, 
as  I  have  shown  in  "Internal  Secretions,"  is 
merely  an  experimental  phenomenon  brought 
about  by  excessive  constriction  of  the  intes- 
tinal vessels)  is  offset  by  severing  the  nerves 
to  the  adrenals.  This  fact,  first  observed  by 
Jacobi  (Arch.  f.  exper.  Pathol.,  Bd.  xxix,  S. 
171,  1892),  proves,  from  my  viewpoint,  that 
two  sources  of  vasoconstriction  (manifested 
by  elevation  of  the  blood-pressure)  must 
always  be  taken  into  account:  (1)  that  due 
to  yaspmotor  nerves,   and    (2)    that   due  to 


increased  activity  of  the  adrenals.  It  is  by 
producing  a  similar  constriction  of  the  arte- 
rioles that  opium  and  its  analgesic  alkaloids 
cause  constipation  and  relieve  pain — accord- 
ing to  my  views.     C.  E.  de  M.  S.] 

Physiology  of  Local  Action. — The 
local  application  of  an  adrenal  prin- 
ciple, adrenalin,  epinephrin,  etc.,  causes 
such  marked  contraction  of  the  vessels 
that  their  lumina,  when  applied  over 
small  vessels,  may  become  obliterated, 
thus  arresting  totally  the  flow  of  blood. 
The  tissues  become  very  pale,  there- 
fore, and  even  blanched.  These  effects, 
however,  are  of  short  duration.  Mu- 
cous membranes  are  similarly  affected ; 
hence,  the  frequent  use  of  adrenal  ex- 
tractives on  the  nasal  mucosa  and  the 
conjunctiva.  The  constrictive  effect  on 
the  blood-vessels  is  due  to  a  direct  ac- 
tion on  their  muscular  elements;  ap- 
plied to  the  eye,  adrenal  extractives 
also  produce  contraction  of  its  muscles. 
Hence,  the  dilatation  of  the  pupil,  the 
wide  separation  of  the  eyelids,  and  ap- 
parent protrusion  of  the  eyeball.  From 
my  viewpoint,  the  contraction  of  the 
vessels  produced  by  adrenalin  and  the 
resultant  blanching  are  due  to  the  in- 
creased metabolic  activity  it  awakens 
temporarily  in  the  vascular  and  other 
tissues  to  which  it  is  applied. 

[The  process  does  not  differ  from  that 
which  obtains  in  the  blood.  It  is  that  of 
exaggerated  oxidation  in  which  the  adren- 
alin, as  I  have  pointed  out,  plays  the  part 
of  a  catalyzer.  Poehl  found  that  the  ad- 
renal active  principle  was  endowed  with 
catalytic  properties.  This  enables  it  to  acti- 
vate greatly  the  process  of  oxidation  with- 
out being  itself  rapidly  consumed — its  action 
recalling  that  of  a  ferment.  Jolles  showed, 
moreover,  that  the  catalytic  activity  of  a 
given  volume  of  blood  corresponded  with  the 
number  of  red  corpuscles  it  contained. 
These  corpuscles  being  the  carriers  of  hemo- 
globin, which,  in  turn,  contains  the  adrenal 
principle,  as  I  have  shown,  adrenalin,  when 
applied   to    the   tissues,    acts   as    if   a   large 


758 


ANIMAL   EXTRACTS    (SAJOUS). 


amount  of  oxyhemoglobin  had  been  concen- 
trated upon  it.     C.  E.  deM.  S.] 

PREPARATIONS  AND  DOSE.— 

The  preparations  most  generally  used 
are  the  dried  gland,  the  glandular  siipra- 
fcnalis  sicccs  of  the  1905  U.  S.  P.,  avail- 
able in  tablets  or  powder,  the  dose  of 
which  is  2  to  10  grains,  and  the  active 
principle  epinephrin,  now  generally  ac- 
cepted as  the  official  name  for  several 
proprietary  preparations,  such  as 
adrenalin,  suprarenalin,  supracapsulin, 
adrin,  etc.  Synthetic  epinephrin  is 
also  available,  but  there  is  no  ground 
upon  which  it  should  be  given  prefer- 
ence over  active  principle  obtained  from 
the  adrenals.  As  shown  by  Shultz, 
Cushny,  and  others,  the  synthetic  prod- 
ucts are  about  one-half  the  strength 
of  the  natural.  Though  the  latter  also 
vary  in  physiological  activity  somewhat, 
the  solutions  available  are  uniformly 
of  1 :  1000,  the  doses  of  which  are :  By 
the  mouth,  10  to  30  minims;  intramus- 
cularly or  hypodermically,  if  the  region 
is  massaged,  3  to  15  minims,  always  in 
free  dilution  with  saline  solution.  In- 
travenously, it  should  only  be  given 
drop  by  drop  in  large  dilution '  with 
saline  solution,  the  latter  being  used  as 
in  hypodermoclysis.  The  use  of  strong 
solutions  of  1 :  1000  solution  intra- 
venously is  always  fraught  with  con- 
siderable danger. 

The  writer  urges  that  adrenal  prep- 
arations be  used  greatly  diluted,  as  this 
reduces  materially  the  toxic  action,  even 
of  the  same  dose;  he  also  pleads  for 
caution  in  the  estimations  of  the  in- 
dividual reaction  in  the  given  case,  espe- 
cially the  exact  state  of  the  heart  and 
the  vessels.  He  warns  against  intra- 
venous injection,  and  emphasizes  the 
necessity  for  extreme  care  in  injecting 
the  preparation  where  it  might  get  into 
a  vein.  The  vaginal  portion  of  the 
uterus  can  be  rendered  anemic  effect- 
ually and  safely  by  injection  of  only  10 


c.c.  of  200  c.c.  of  salt  solution  contain- 
ing merely  1  c.c.  of  the  1  per  thousand 
solution  of  suprarenin — there  is  no 
need  to  use  a  stronger  concentration. 
Neu  (Zentralbl.  f.  Gynak.,  July  24, 
1909). 

Two  fatal  cases  due  to  the  use  of 
suprarenin  injected  into  the  cervix  for 
operative  purposes.  The  author  and 
other  surgeons  and  dentists  have  made 
use  of  this  drug  in  thousands  of  cases 
for  local  anesthesia,  combined  with 
other  drugs,  and  have  experienced  no 
bad  effects.  As  to  the  cause,  there  is 
no  fixed  poisonous  amount  of  this 
drug;  this  varies  with  the  individual, 
and  with  the  way  in  which  it  is  used. 
The  writer  uses  a  very  weak  solution 
injected  in  considerable  amount.  It  is 
not  the  amount  of  the  drug  or  of 
the  solution  used,  but  the  concentration 
of  the  solution,  that  does  harm.  A 
large  amount  of  a  weak  solution  can 
be  used  without  danger,  while  a  small 
amount  of  a  strong  solution  will  be 
fatal.  The  method  in  which  the  mate- 
rial is  introduced  is  also  of  importance. 
Injected  intravenously  it  will  have  an 
immediate  bad  effect,  while  applied 
locally  or  subcutaneously  it  will  be  well 
borne.  The  author  combines  it  with  a 
J4  per  cent,  solution  of  novocaine,  and 
to  100  c.c.  of  this  solution  he  adds  0.64 
Gm.  of  borate  of  suprarenin.  The 
drugs  are  made  up  into  a  tablet  and  the 
solution  made  freshly  for  each  opera- 
tion. He  has  no  fear  of  using  as  much 
as  125  c.c.  of  this  solution  for  an 
operation.  Braun  (Zeit.  f.  Gyn.,  July 
24,  1909). 

As  I  pointed  out  in  1907,  it  is  very 
doubtful  whether  epinephrin,  adren- 
alin, or  any  of  the  adrenal  active  prin- 
ciples are  physiologically  active  in  so 
far  as  the  general  system  is  concerned. 
This  I  attribute  to  the  fact  that  gas- 
tric secretions  give  the  oxidase  reac- 
tions (guaiac,  etc.),  thus  showing  that 
they  can  oxidize  them  before  they 
reach  the  circulation  at  all,  and  are 
thus  deprived  of  their  physiological 
properties, 


ANIMAL   EXTRACTS    (SAJOUS). 


759 


Adrenalin  injected  subcutancously  or 
into  the  peritoneum  in  laboratory  ani- 
mals has  a  marked  toxic  action  and  no 
adrenalin  appears  in  the  urine.  On  the 
other  hand,  20  times  this  dosage  and 
more,  given  by  the  mouth,  causes  no 
signs  of  toxic  action,  while  consider- 
able amounts  of  adrenalin  are  elimi- 
nated in  the  urine.  The  author  thinks 
that  under  the  influence  of  the  digestive 
juice  and  of  the  mucosa  the  adrenalin 
becomes  bound  in  some  way  which  de- 
prives it  of  its  physiological  and  toxic 
properties.  Further  research  seems  to 
demonstrate  that  the  deintoxication  of 
adrenalin  occurs  not  in  the  liver,  but 
in  the  gastrointestinal  canal.  Falta 
(Wiener  klin.  Woch.,  Dec.  23,  1909). 

This  does  not  apply  to  the  dried 
gland,  probably  because  the  active  prin- 
ciple is  bound  up  in  organic  combina- 
tion. S.  Solis-Cohen  found,  more- 
over, that,  by  masticating  the  dried 
gland  without  sw^allowing  it,  the 
physiological  effects  manifested  them- 
selves. The  active  principle  proper, 
adrenalin,  etc.,  are,  nevertheless,  ab- 
sorbed from  the  colon,  especially 
when  administered  with  saline  solu- 
tion. 

Each  of  the  epinephrin  preparations, 
suprarenalin,  adrenalin,  etc.,  available 
is  also  conveniently  put  up  as  an  in- 
halant, ointmen't,  and  suppositories,  the 
strength  being  also  1 :  1000  in  neutral 
oil,  petrolatum,  or  oil  of  theobroma  in 
the  order  of  the  preparations  named, 
and  some  mild  antiseptic  to  preserve 
the  latter. 

UNTOWARD  EFFECTS.— In  the 
frog  toxic  doses  produce  a  temporary 
paresis,  the  muscles  acquiring  marked 
rigidity.  This  is  ascribed  by  some  to 
poisoning  of  the  spinal  cord,  by  others 
to  a  direct  action  on  the  muscles.  In 
mammals  large  doses  given  subcuta- 
ncously cayse  excitement,  tremor  and 
vomiting,    paralysis    beginning    at    the 


posterior  extremities,  polyuria,  and 
dyspnea,  death  occurring  either 
through  respiratory  failure  or  cardiac 
arrest.  In  the  cat,  however,  which 
bears  larger  doses  than  other  animals, 
the  respiration  ceases,  as  a  rule,  before 
the  heart's  action  is  arrested.  This  is 
due  to  pulmonary  edema,  according  to 
some  authors,  and  to  paralysis  of  the 
respiratory  centers,  according  to  oth- 
ers. \\lien  the  poison  is  injected  into 
a  vein  the  morbid  effects  are  preceded 
by  a  very  rapid  and  marked  rise  of  the 
blood-pressure. 

Man  is  more  susceptible  to  the  action 
of  adrenalin  than  animals.  While  a 
subcutaneous  injection  of  1  dram  (4 
c.c.)  of  a  1 :  1000  solution  will  hardly 
affect  a  rabbit,  one-third  of  that  quan- 
tity has  produced  untoward  effects  in 
normal  as  well  as  in  tuberculous  sub- 
jects (Souques  and  Morel),  e.g.,  ver- 
tigo, nausea,  vomiting,  severe  pain  un- 
der the  sternum  similar  to  that  of 
angina  pectoris,  and  a  feeling  of  con- 
striction about  the  chest,  a  rapid  pulse, 
dyspnea,  cold  sweats,  and  coldness  of 
the  extremities. 

Two  fatalities  following  injection  of 
adrenalin  into  the  vaginal  portion  of 
the  uterus.  The  first  patient  was  a 
woman  of  47  with  total  prolapse  of  the 
uterus,  the  vaginal  portion  of  which 
was  much  hypertrophied.  Under  chlor- 
oform the  fluid,  consisting  of  1  c.c.  of 
adrenalin  solution  in  10  c.c.  of  0.8  per 
cent,  salt  solution,  was  injected  at  3 
points  when  suddenly  retching  occurred, 
respiration  and  pulse  stopped,  and  it 
proved  impossible  to  revive  the  patient. 
Ten  days  later  the  same  syndrome  with 
instant  death  occurred  in  a  similar  case, 
the  patient  being  a  robust  woman  of  ZZ 
with  a  hemorrhagic  metritis  and  fibrous 
hypertrophy^  of  the  neck  of  the  uterus 
requiring  wedge  resection.  Some  of 
the  fluid  used  was  injected  into  rabbits, 
but  showed  no  injurious  by-effects. 
The  dose  was  very  small  in  these  cases, 


760 


ANIMAL   EXTRACTS    (SAJOUS). 


not  more  than  0.0003  Gm.  of  active 
adrenalin.  N.  N.  (Zentralbl.  f.  Gynak., 
June  19,  1909). 

Intoxication  may  also  follow  the  use 
of  adrenalin  when  injected  into  cav- 
ities, such  as  the  vagina,  the  rectum, 
the  urethra,  when  the  mucous  mem- 
brane is  abraded,  lacerated,  or  denuded, 
thus  rendering  its  absorption  possible. 

Case  in  a  negro  aged  26,  male,  very- 
rugged,  had  a  stricture  of  the  urethra. 
After  some  difficulty  the  author  suc- 
ceeded in  passing  a  No.  24  French 
sound.  When  the  sound  was  with- 
drawn considerable  blood  followed  it, 
which  greatly  alarmed  the  patient. 
Thinking  to  quiet  his  fears,  half  a  dram 
of  adrenalin  chloride  (1:1000)  was  in- 
jected. In  about  thirty  seconds  the 
patient  became  restless  and  moved 
about,  staggered,  and  was  laid  on  the 
couch.  He  complained  of  intense  pain 
about  the  heart,  and  his  breathing  was 
labored  and  very  rapid.  The  heart-beat 
was  so  fast  that  it  could  not  be  counted. 
The  conjunctiva  was  blanched.  Pro- 
fuse perspiration  broke  out  all  over  the 
body,  and  the  extremities  became  very 
cold.  The  man  declared  that  he  was 
dying,  and  the  writer  was  inclined  to 
believe  him.  In  about  five  minutes  he 
began  to  cough  and  spat  up  mouthfuls 
of  bloody  froth.  The  coughing  and 
spitting  of  blood  continued  for  over  an 
hour.  The  pulse,  which  had  been  very 
hard,  became   soft   and  slow. 

Morphine,  atropine,  and  nitroglyc- 
erin hypodermically  were  given  dur- 
ing the  continuance  of  the  alarming 
symptoms.  The  patient  gradually  be- 
came quieter,  and  the  symptoms  sub- 
sided. He  slept  fairly  well  the  follow- 
ing night  and  rose  the  next  day  very 
little  the  worse  for  his  experience. 
F.  C.  Bennett  (Jour.  Amer.  Med. 
Assoc,  Nov.  17,  1906). 

Case  of  a  man  aged  26  weighing  190 
pounds,  heart  and  lungs  normal,  in 
whom,  to  arrest  bleeding  caused  by 
manipulation  of  the  urethra  to  render 
a  stricture  passable,  10  minims  of  a 
1 :  1000  solution  of  suprarenal  principle 
were     injected     through     an     Ultzman 


instillator.  The  patient  immediately 
complained  of  pain  in  the  stomach,  and 
a  condition  of  profound  shock  stiper- 
vened.  He  complained  of  air-hunger, 
vomited,  and  lapsed  into  syncope.  As 
the  pulse  became  slower  and  finally  dis- 
appeared, and  death  seemed  imminent, 
Yso  grain  of  strychnine  and  %oo  grain 
of  nitroglycerin  were  given  hypoder- 
mically. In  ten  minutes  the  radial  pulse 
began  to  return,  and  within  an  hour 
the  patient  left  the  office  unassisted. 
Next  day  progressive  dilatation  of  the 
stricture  was  practised  without  the  aid 
of  the  adrenal  preparation.  Link  (Cen- 
tral States  Med.  Monitor,  Sept.,  1907). 

The  prolonged  use  of  adrenal  prepa- 
rations may  induce  chronic  adrenalism, 
manifested  by  marked  cardiac  disor- 
ders, especially  of  the  myocardium; 
dyspnea  after  slight  exertion,  tachy- 
cardia, high  blood-pressure,  polyuria, 
icteric  staining  of  the  conjunctiva,  and 
marked  increase  in  weight. 

Case  of  a  man  who  during  one  year 
and  nine  months  applied  daily  to  the 
conjunctiva,  as  a  treatment  for  conjunc- 
tivitis, a  solution  of  adrenalin  chloride. 
Palpitations,  with  marked  increase  of 
the  arterial  tension,  cardiac  dyspnea  on 
exertion,  and  polyuria,  were  followed 
by  a  yellowish  tinge  of  the  conjunctiva 
such  as  that  observed  in  jaundice.  A 
curious  feature  of  the  case  was  that 
the  patient  gained  in  weight  rapidly. 
Cessation  of  the  instillations  and  regu- 
lation of  the  diet  caused  a  gradual 
retrogression  of  these  symptoms,  but 
there  remained  some  cardiac  weakness. 
K.  Feiler  (Med.  Klinik,  May  17,  1908). 

Local  applications  are  sometimes  fol- 
lowed by  untoward  effects  in  the  tissues 
to  which  epinephrin  solutions  are  ap- 
plied. Repeated  applications,  especially 
with  the  atomizer,  of  anything  but 
weak  solutions  (1 :  10,000)  to  the  nasal 
cavities  or  pharynx  may  give  rise  to 
edema  of  the  nasal  mucosa,  the  uvula, 
tonsils,  or  pillars  of  the  fauces.  This 
is  ascribed  by  most  writers  to  "violent 


ANIMAL  EXTRACTS    (SAJOUS). 


761 


vasomotor  constriction  of  the  blood- 
vessels" and  the  resulting  "venous  stag- 
nation.'' In  some  instances  they  cause 
persistent  sneezing  and  acute  coryza 
accompanied  at  times  by  severe  pain  in 
the  upper  portion  of  the  nasal  cavities. 

Case  of  a  man  aged  39,  of  good 
habits  and  good  health,  except  for  his 
periodic  attacks  of  hay  fever,  who  was 
advised  by  a  lay  friend  to  use  one  of 
the  well-known  preparations  of  the 
suprarenal  gland,  and  supplied  himself 
with  the  remedy  and  an  atomizer  in  the 
summer  of  1905.  He  used  it  several 
times  a  day  during  his  attack. 

When  the  hay  fever  subsided  he 
noticed  that  there  was  a  fullness  in  his 
nose  that  did  not  disappear,  but,  on  the 
contrary,  became  more  marked.  He 
was  treated  by  his  physician  for  a  time 
without  relief,  and  then  sought  the  aid 
of  a  rhinologist.  The  condition  refused 
to  yield  to  any  form  of  treatment,  and, 
symptoms  of  Eustachian  congestion 
supervening,  it  became  necessary  to  re- 
move portions  of  both  middle  tur- 
binates. After  a  long  course  of  treat- 
ment he  went  to  his  home  improved, 
but  bearing  traces  of  the  condition 
with  him.  Two  other  very  similar 
cases  witnessed.  B.  H.  Potts  (Jour. 
Amer.  Med.  Assoc,  Oct.  13,  1906). 

Adrenalin,  when  applied  to  the  gums 
on  cotton-wool — whether  to  stop  bleed- 
ing or,  as  has  been  recommended  in 
the  preparation  of  cavities,  to  control 
the  saliva  exuding  from  the  mucous 
glands  at  the  neck  of  the  teeth — should 
be  used  with  great  caution.  The  cotton- 
wool with  the  adrenalin  solution  should 
be  thoroughly  squeezed  to.  remove  ex- 
cess before  applying. 

The  writer  had  occasion  to  witness 
recently  a  distinct  case  of  adrenalin 
poisoning  in  which  it  had  been  used  to 
stop  bleeding.  Evidently  in  this  case 
the  adrenalin  had  been  applied  freely, 
and,  on  pressure  being  used  to  the  pad 
of  cotton-wool,  a  few  drops  of  the 
excess  adrenalin  had  been  squeezed 
out.  The  symptoms  were  alarming, 
being  not  unlike  an  epileptic  seizure, 
and    the    patient    remained   in    a    col- 


lapsed condition  for  some  hours  after. 
Anonymous  (Chemist  and  Druggist; 
Prescriber,  March,  1911). 

Some  cases  have  been  reported  in 
which  sloughing  and  gangrene  of  the 
mucosa  occurred.  Elderly  subjects  are 
prone  to  this  complication,  according 
to  Neugebauer.  Postoperative  hemor- 
rhages are  not  infrequently  noticed  af- 
ter the  use  of  adrenalin,  owing  to  re- 
laxation of  the  severed  vessels. 

A  rather  extensive  use  of  suprarenal 
extract  in  intranasal  operations  showed 
that  there  is  a  marked  tendency  toward 
secondary  hemorrhage,  the  bleeding 
coming  on  in  from  two  to  four  hours 
after  the  operation.  Letters  to  a  num- 
ber of  specialists  brought  out  the  fact 
that  with  one  exception  they  all  experi- 
enced the  same  trouble.  The  mixture  of 
cocaine  and  suprarenal  is  followed  by 
relaxation  sooner  than  when  the  supra- 
renal is  used  by  itself  in  the  majority 
of  cases.  After  operating  in  the  nose 
when  suprarenal  extract  is  used  it  is 
best  in  every  instance  to  pack  the  fossa 
and  so  be  on  guard  against  the  second- 
ary bleeding.  A  less  common  sequela 
to  the  use  of  suprarenal  is  an  intense 
coryza  induced  by  the  secondary  relaxa- 
tion. F.  E.  Hopkins  (N.  Y.  Med.  Jour., 
Aug.  25,  1900). 

In  the  larynx,  epinephrin  solutions 
cause  an  uncomfortable  dryness  by  in- 
terfering with  the  formation  of  lubri- 
cating mucus.  This  is  especially  dis- 
tressing to  singers.  In  the  eye  their 
use  in  scleritis  and  other  disorders  may 
be  followed  by  severe  iritis.  Instilla- 
tions of  a  1 :  1000  solution  in  the  Eusta- 
chian tubes  have  given  rise  to  violent 
pain  in  the  middle  ear,  which  was  re- 
newed whenever  the  remedy  was  thus 
administered.  The  use  of  adrenalin 
solutions,  in  the  form  of  a  spray  at 
least,  is  contraindicated  in  infections, 
owing  to  the  danger  of  facilitating  the 
entrance  of  pathogenic  germs  into  the 
sinuses. 


762 


ANIMAL  EXTRACTS    (SAJOUS). 


A  fresh  case  of  influenza  with  severe 
coryza  is  a  distinct  contraindication  to 
its  use.  The  drug  by  causing  contrac- 
tion of  the  tissues  dilates  all  the  cranial 
sinuses,  and,  if  the  patient  unguardedly 
uses  his  handkerchief  while  the  mucous 
membranes  are  under  the  influence  of 
the  drug,  bacteria  will  be  certainly 
blown  into  the  antrum  of  Highmore, 
probably  into  the  ethmoid  cells  and  the 
middle  ear,  and  possibly  into  the  frontal 
sinuses  as  well.  Empyema  of  all  the 
sinuses  named  has  thus  been  caused.  J. 
J.  Kyle    (Pediatrics,  Feb.   15,   1902). 

The  role  I  attribute  to  the  adrenal 
secretion  in  oxidation,  metabolism,  and 
nutrition  is  as  applicable  to  the  unto- 
ward phenomena  as  it  was  to  the  thera- 
peutic action  of  the  drug.  Following 
the  course  of  events  from,  start  to  fin- 
ish, we  have  at  first  the  effects  of  ex- 
cessive metabolism  in  all  tissues :  in 
the  cerebrospinal  system,  excitement; 
in  the  muscles,  tremor;  in  the  kidneys, 
polyuria;  in  the  myocardium,  violent 
contractions  (palpitations)  ;  in  the 
muscular  coats  of  the  vascular  system, 
a  marked  rise  of  the  blood-pressure. 
The  latter  in  turn  aggravates  the  proc- 
ess by  causing  congestion  and  en- 
gorgement of  the  capillaries  (which  are 
not,  like  the  arteries,  provided  with  a 
muscular  coat)  of  all  organs,  including 
the  lungs,  causing  edema  of  these  struc- 
tures and  dyspnea.  As  the  contraction 
of  the  arteries  proceeds,  the  aorta  has 
to  bear  the  brunt  of  the  centrifugal 
pressure,  giving  rise  to  marked  sub- 
sternal pain.  When  it  becomes  such 
that  the  arterioles  obstruct  the  circu- 
lation the  lethal  phenomena  are  initi- 
ated :  the  pulmonary  circulation  being 
impeded,  oxygenation  fails  to  occur, 
asphyxia  follows,  and,  the  myocardium 
receiving  too  little  blood  to  sustain  its 
contractile  power,  the  heart,  already 
hampered  by  the  pulmonary  congestion, 
ceases  to  beat. 


In  chronic  adrenalism  the  same  in- 
terpretation obtains,  the  cardiac  phe- 
nomena being  ascribable  mainly  to  the 
extra  work  imposed  upon  the  heart  by 
the  resistance  of  the  general  vascular 
tension.  The  gain  in  weight  is  a  nor- 
mal result  of  increased  metabolic  ac- 
tivity, i.e.,  overnutrition. 

[In  the  first  volume  of  "Internal  Secre- 
tions" (pp.  192  et  seq.,  1st  ed.)  I  pointed  out 
in  1903  that  the  overgrowth  in  acromegaly 
and  gigantism  was  due  to  overactivity  of  the 
adrenals.  The  correctness  of  this  view, 
based  on  many  experimental  and  clinical 
facts,  was  shown  by  the  observations  of  L. 
G.  Guthrie  (Brit.  Med.  Jour.,  Sept.  21,  1907), 
who  referred  to  a  series  of  cases  of  over- 
growth in  children — 1  personal  and  5  from 
literature,  in  all  of  which  "adrenal  tumors 
existed."  One  of  these,  for  instance,  a  child 
of  3  years,  was  prematurely  developed  and 
weighed  44  pounds.  Guthrie,  as  I  had  four 
years  earlier,  ascribed  the  overgrowth  to 
hypersecretion  of  the  adrenals.  C.  E. 
deM.  S.] 

After  local  applications  the  morbid 
effects  are  all  the  result  of  the  action  of 
the  adrenal  principle  upon  the  ves- 
sels. 

The  dryness  produced  by  solutions 
sprayed  into  the  larynx  is  due  to  defi- 
ciency of  blood  supplied  to  the  acini 
and  the  resulting  inhibition  of  their 
function.  If  this  is  kept  up  by  repeated 
applications,  the  tissues,  no  longer 
nourished,  may  slough  off,  as  has  been 
noticed  in  the  upper  respiratory  tract 
of  aged  subjects.  The  edema  observed 
in  this  location  is  not  active,  as  it  is  in 
the  lungs,  but  passive,  i.e.,  due  to  ex- 
aggerated relaxation  of  the  vessels  af- 
ter the  intense  constriction  to  which 
the  drug  had  subjected  them.  This 
applies  equally  well  to  postoperative 
hemorrhage,  and  to  the  severe  pain 
(due  to  passive  congestion)  in  the 
middle  ear  after  instillations  in  the 
Eustachian  orifice. 


AiSriMAL   EXTRACTS    (SAJOUS). 


^63 


THERAPEUTICS.— Addison's 
Disease. — Textbooks  of  practice  and 
therapeutics  now  teach  pretty  gen- 
erally that  adrenal  preparations  are  of 
value  in  Addison's  disease.  A  personal 
study  of  the  literature  of  the  subject 
sho\Yed  that  out  of  120  cases  treated  by 
adrenal  preparations  25  had  been  suffi- 
ciently benefited  to  be  restored  to 
health — as  far,  at  least,  as  the  loss  of 
adrenal  tissue  incurred  through  the 
local  morbid  process  would  permit. 

The  one  great  factor  in  the  treatment 
of  this  affection  by  means  of  adrenal 
extractives  is  to  drop  their  empirical 
use,  and  it  is  only  (and  this  applies  to 
the  use  of  any  disease)  when  the  im- 
portance of  this  fact  will  have  been 
thoroughly  grasped  that  the  proportion 
of  recoveries  will  be  materially  in- 
creased. Empiricism  here  may  entail 
death. 

[E.  W.  Adams  (Practitiofter,  Oct.,  1903) 
refers  to  a  group  of  7  cases  found  by  him 
in  literature  "in  which  alarming  or  fatal  re- 
sults were  presumably  or  possibly  due  to 
the  treatment."  He  mentions,  for  instance, 
2  cases  reported  by  a  prominent  clinician 
treated  with  "suprarenal  gland  extract." 
The  chart  notes  of  the  cases  include  the  la- 
conic words:  "Alarming  collapse.  One  of 
the  cases  began  to  improve  markedly  when 
the  extract  was  stopped."  In  the  original 
paper  reference  is  made  to  another  case 
treated  by  suprarenal  extract  in  which 
"similar  collapse  was  noted."  The  dose  was 
not  mentioned.  Such  cases  are  apt  to  be 
regarded  as  examples  of  the  sudden  death 
sometimes  observed  in  Addison's  disease,  to 
which  Addison  himself,  Dieulafoy,  Ander- 
son, Bradbury,  and  others  haA'e  called  atten- 
tion ;  but  this  explanation  does  not  hold. 
Guiol  (Bull,  de  la  Soc.  medico-chir.  du  Var.. 
Dec,  1906),  having  observed  similar  signs  of 
intoxication  and  collapse,  tried  the  "remedy" 
in  a  normal  subject  and  obtained  the  same 
morbid  phenomena.  Here,  again,  we  are 
dealing  with  fatalities  which  occurred  when 
the  physiological  functions  of  the  organs, 
and,  therefore,   their   mode   of   action   as   a 


tlicrapcutic  agent,  were  6ut  slightly  known. 
C.  E.  DE  M.  S.] 

The  salient  guides  in  the  use  of  these 
preparations  are  the  low  temperature, 
which  denotes  deficient  oxidation  and 
metabolism,  and  the  zceak  pulse,  which 
points  to  a  low  vascular  tension  and 
inadequate  cardiac  dynamism.  Im- 
provement of  a  given  case  is  indicated 
by  a  gradual  resumption  of  normal 
conditions  in  these  two  directions,  and 
by  the  return  of  bodily  vigor,  with 
more  or  less  fading  of  the  pigmenta- 
tion. As  a  rtde,  the  more  these  various 
morbid  phenomena  are  marked,  the 
larger  will  be  the  initial  dose  required. 
In  other  words,  marked  hypothermia, 
a  very  feeble  pulse,  advanced  bronzing, 
and  great  debility  will  indicate  that  a 
mere  vestige  of  both  adrenals  is  still 
active;  the  dose  indicated,  then,  is  that 
which  will  supply  enough  additional 
principle  to  raise  the  temperature  and 
the  blood-pressure  to  normal,  but  not 
beyond.  A  study  of  the  120  above- 
mentioned  cases  has  shown  that  3 
grains  (0.2  Gm.)  of  the  desiccated 
gland  three  times  daily  was  the  most 
satisfactory  dose  to  start  with.  If  this 
fails  to  raise  the  temperature  and  the 
pulse  tension  or  improve  the  case,  the 
dose  should  be  increased  by  1  grain 
per  day  until  it  does,  the  case  being 
watched  closely.  As  soon  as  the  nor- 
mal temperature  is  reached,  the  dose 
should  no  longer  be  increased,  unless  a 
tendency  to  recurrence  of  the  hypo- 
thermia (gradually  as  the  adrenals  are 
being  destroyed  by  the  local  morbid 
process)  should  render  it  necessary.  In 
less  advanced  cases  the  initial  doses 
should  be  correspondingly  small,  2  or 
even  1  grain  of  the  extract  being  ad- 
ministered three  times  daily,  the  dose 
decreasing  in  proportion  as  the  disease 
is  less  advanced. 


;64 


ANIMAL  EXTRACTS    (SAJOUS). 


Can  v/e  expect  a  cure  from  adrenal 
preparations?  In  most  cases  of  Addi- 
son's disease  the  local  process  is  tuber- 
cular— often  limited  to  the  adrenals.  A 
number  of  examples  suggest,  however, 
that  the  tubercular  process  itself  was 
benefited,  and  even  cured,  by  the  use 
of  adrenal  extract.  This  is  quite  in 
accord  with  the  view  I  have  advanced, 
and  sustained  by  considerable  evidence 
("Internal  Secretions,"  vol.  i,  1903, 
and  vol.  ii,  1907;  see  also  N.  Y.  Med. 
Jour.,  Feb.  20  and  27,  1909)  that  the 
adrenal  secretion  sustains  the  efficiency 
of  the  immunizing  mechanism. 

A  number  of  cases  are  on  record  in 
which,  after  apparent  recovery,  the 
cases  died  suddenly  soon  after  ceasing 
the  use  of  adrenal  preparations.  It  is 
evident  that  even  the  possibility  of 
curing  the  morbid  process  in  the  adre- 
nals does  not  replace  the  destroyed 
adrenal  tissue.  It  is  here  that  grafting 
would  be  of  curative  value,  but  only 
provided  small  fragments  of  adrenal 
tissue  be  inserted,  and  gradually  in- 
creased in  number  until  the  tempera- 
ture and  pulse  indicate  that  compensa- 
tion for  the  functionless  areas  in  the 
adrenals  has  been  increased. 

The  120  cases  analyzed  showed  also, 
and  my  own  experience  has  further 
demonstrated,  that  what  is  generally 
known  as  "adrenal  extract,"  but  which, 
in  reality,  is  the  desiccated  adrenal 
gland  (the  glandules  suprarenales  siccce 
of  the  U.  S.  P),  is  by  far  the  most  sat- 
isfactory agent  to  use.  Injections  of 
adrenal  fluidextracts  are  exceedingly 
painful — a  fact  which  compromises  the 
issue  by  introducing  the  element  of 
shock— while  the  active  principles, 
epinephrin,  adrenalin,  suprarenalin, 
etc.,  sometimes  fail  altogether  to  act, 
owing  to  their  becoming  oxidized  and 
rendered    inert    while    being    absorbed. 


The  fresh  gland  is,  as  a  rule,  repulsive 
to  the  patient,  and  tends  to  aggravate 
the  tendency  to  nausea  and  vomiting. 

See,  also,  Addison's  Disease,  Treat- 
ment OF,  this  volume. 

Shock,  Collapse,  and  Surgical  Dis- 
eases.— This  is  another  condition  in 
which  adrenal  preparations  show 
prominently  their  influence  on  metabo- 
lism. The  function  I  ascribe  to  the 
adrenal  secretion  (to  take  up  the  oxy- 
gen of  the  air,  and  be  carried  to  the 
tissues  where  its  active  principle  aug- 
ments greatly  the  activity  of  this  gas) 
involves  the  conclusion  that  it  is  a 
prominent  factor  in  the  sustenance  of 
the  body  heat,  a  fact  demonstrated  by 
Reichert,  Lepine,  Morel,  and  others. 
Now,  Kinnaman,  in  a  comprehensive 
study  of  the  temperature  relationship 
to  shock,  concluded  that  as  shock  in- 
creased in  severity  the  most  uniform 
progressive  factor  was  the  fall  in  tem- 
perature. He  states  that  "in  one  series 
[of  cases]  the  fall  in  temperature  was 
the  sole  cause  of  shock."  The  results 
of  Crile  with  adrenalin  in  salt  solution 
given  very  slowly  and  gradually  for  a 
considerable  time  thus  find  a  normal 
explanation  in  my  interpretation  of  the 
role  of  the  adrenal  secretion.  He  sup- 
plied the  organism  precisely  with  the 
substance  which  sustains  the  vital  proc- 
ess in  the  tissue-cells.  Indeed,  he  re- 
suscitated animals  in  this  manner — with 
simultaneous  artificial  respiration — fif- 
teen minutes  after  all  signs  of  life  had 
ceased,  and  was  able  to  keep  a  decap- 
itated dog  alive  over  ten  hours  by  this 
same  procedure.  That  it  was  because 
the  adrenal  secretion  is  able  to  sustain 
tissue  metabolism,  i.e.,  the  vital  process 
itself,  that  such  results  were  obtained 
seems  self-evident. 

The  value  of  adrenalin  in  raising  the 
blood-pressure,  by   its   action  upon  the 


ANIMAL   EXTRACTS    (SAJOUS). 


1^1^ 


vascular  walls  in  the  state  of  suspended 
animation,  has  been  thoroughly  estab- 
lished. Introducing  the  adrenalin  into 
the  venous  circulation,  while  easy  and 
practical,  had  the  following  disadvan- 
tage :  the  adrenalin  first  came  in  con- 
tact with  the  vessels  having  the  least 
power  of  influencing  the  blood-pressure, 
and  before  a  material  rise  could  be 
effected  by  its  action  upon  the  arteries 
it  was  necessary  that  the  solution 
should  pass  through  the  right  heart, 
the  lungs,  and  then  back  to  the  left 
heart  on  its  way  to  the  aorta,  then 
finally  affecting  the  coronary  arteries. 
In  a  previous^research  it  was  found  that 
this  too  often  caused  an  accumulation 
of  solution  and  blood  in  the  dilated 
paralyzed  chambers  of  the  heart,  de- 
feating resuscitation. 

It  seemed  reasonable  to  suppose  that 
the  most  direct  and  effective  way  of 
producing  a  coronary  pressure  amount- 
ing to  40  or  more  millimeters  of  mer- 
cury was  by  introducing  a  solution  of 
adrenalin  into  the  arterial  system 
toward  the  heart.  In  this  way  the 
moment  the  adrenalin  was  introduced 
it  caused  a  contraction  of  the  strong 
arterial  walls,  and  began  to  produce  an 
arterial  pressure  which  was  communi- 
cated directly  to  the  coronary  arteries 
without  first  passing  directly  through 
the  already  distended  and  paralyzed 
chambers  of  the  heart  and  through 
the  lungs.  These  considerations  were 
strongly  impressed  upon  the  author  by 
a  clinical  case  of  suspended  animation 
in  the  course  of  a  cerebellar  operation 
on  a  child,  which  was  unexpectedly  re- 
suscitated by  centripetal  arterial  in- 
fusion of  adrenalin. 

The  following  will  serve  as  an  illus- 
tration :  An  animal  was  killed  by 
chloroform.  A  cannula  was  inserted 
into  the  femoral  artery  and  directed 
toward  the  heart.  After  five  minutes , 
artificial  respirations  were  begun,  and 
the  saline  solution  was  given  into  the 
tube  near  the  cannula.  A  few  seconds 
later  the  blood-pressure  began  to  rise 
steadily;  then  a  few  firm  pressures 
upon  the  thorax  over  the  heart  caused 
a  leaping  up  of  high  pulse  waves,  and 
&t  the  end  of  three-quarters  of  a  minute 


the  heart  beat  vigorously,  driving  the 
blood  up  into  the  infusion  bottle,  which 
had  been  to  the  height  of  5  feet.  The 
saline  injection  and  the  cardiac  massage 
were  discontinued,  and  in  a  few  minutes 
irregular  respirations  began  slowly, 
and  increased  in  force  and  frequency 
until  the  normal  was  established.  The 
animal  was  then  definitely  killed. 

In  general,  the  following  sequence  of 
return  of  the  various  functions  and  re- 
flexes was  exhibited  :  vasomotor  action, 
respiration,  corneal  reflex  and  knee- 
jerk  (tendon  reflexes  in  general),  kink- 
ing, cutaneous  reflexes,  partial  or  com- 
plete contraction  of  the  pupils,  and 
light  reflex.  Crile  (Amer.  Jour.  Med. 
Sci.,  April,  1909). 

This  applies  not  only  to  shock,  but 
also  to  surgical  heart-failure,  collapse 
from  hemorrhage,  asphyxia^  and  sub- 
mersion. The  adrenal  principle  (su- 
prarenalin,  adrenalin,  etc.)  promotes 
energetically,  as  a  catalyzer  and  con- 
stituent of  the  hemoglobin,  the  intake 
of  oxygen  and  its  utilization  by  the  tis- 
sue-cells, including  the  muscular  ele- 
ments of  the  cardiovascular  system, 
and  thus  causes  them  to  resume  their 
vital  activity.  It  should  be  very  slowly 
administered  intravenously,  5  minims 
of  the  1000  solution  to  the  pint  of 
warm  (105°  F.)  saline  solution.  In 
urgent  cases  10  drops  of  suprarenalin 
or  adrenalin  in  1  dram  of  saline  solu- 
tion can  be  used  instead,  and  repeated 
at  intervals  until  the  heart  responds. 
Artificial  respiration  hastens  its  effects. 

Intravenous  adrenalin  injections  are 
particularly  indicated  in  acute  danger- 
ous disorders  of  the  heart  and  respira- 
tion. It  constitutes  the  most  active 
remedy  in  the  severe  collapse  that 
sometimes  follows  spinal  anesthesia  and 
narcosis,  and  is  also  of  service  in 
severe  surgical  shock.  In  case  of 
hemorrhage  and  in  peritonitis  a  com- 
bination with  chloride  of  sodium  in- 
fusions is  recommended.  Whenever 
patients  are  rendered  insensible,  adren- 


766 


ANIMAL   EXTRACTS    (SAJOUS). 


alin  should  be  kept  on  hand  besides 
other  excitants,  such  as  camphor,  etc. 
The  dose  for  intravenous  injection  is 
^  to  1  c.c.  of  a  1  per  cent,  solution 
undiluted,  or  diluted  20  times — that  is 
to  say,  from  10  to  20  drops  in  11  of 
physiological  salt  solution.  Kothe 
(Therap.  der   Gegenwart,   Feb.,   1909). 

The  use  of  suprarenal  preparations  in 
cases  of  acute  cardiovascular  collapse 
highly  recommended.  Their  action  is 
prompt,  and  their  use  may  often  tide 
the  patient  past  the  danger  point.  The 
Mrriter  reports  7  cases  in  which  he  has 
had  good  results  from  their  use.  In  1 
of  the  cases  he  failed  to  follow  up  the 
remarkable  benefit  from  a  single  in- 
jection, and  ascribes  the  fatal  outcome 
to  his  failure  to  continue  the  injections. 
Sohn  (Miinch.  med.  Woch.,  Bd.  xxiv, 
S.  1221,  1909). 

In  collapse  from  weakness  of  the 
vasomotor  center,  such  as  is  liable  in 
pneumonia,  diphtheria,  and  peritonitis, 
good  results  may  be  obtained  with  a 
suprarenal  preparation  injected  into  a 
vein,  or,  diluted  with  salt  solution,  in- 
jected subcutaneously.  Case  of  un- 
complicated ileus  in  which  by  this 
means  it  proved  possible  to  tide  the 
apparently  moribund  patient  past  the 
danger  stage  after  two  days  of  fecal 
vomiting,  and  thus  permitted  a  suc- 
cessful operation.  Heidenhain  (Deut. 
Zeit.  f.  Chir.,  April,  1910). 

Research  showing  that  epinephrin  has 
no  cumulative  action.  Its  action  only 
on  direct  contact.  The  continual  in- 
fusion of  a  weak  solution  of  epinephrin 
may  prove  a  useful  measure  in  thera- 
peutics. It  is  thus  possible  to  send  the 
solution  continuously  into  a  vein  and 
thus  keep  up  the  blood-pressure  per- 
manently while  this  is  being  done — the 
effect  being  dependent  on  the  concen- 
tration of  the  solution,  not  on  the 
absolute  amount  of  epinephrin  infused. 
Straub  (Miinch.  med.  Woch.,  June  27, 
1911). 

Reference  was  made  under  "Un- 
toward Effects"  to  the  dangers  at- 
tending the  use  of  the  adrenal  prin- 
ciples in  surgery  to  produce  ischemia 


at  the  seat  of  operation.  Though  such 
effects  are  not  often  met  with,  the 
fact  remains  that  they  should  be  borne 
in  mind  and  the  principle  that  it 
is  the  free  dilution  of  supracapsulin, 
adrenalin,  etc.,  that  promotes  safety. 
Surgical  operations  can  also  be  per- 
formed without  loss  of  blood,  except 
from  the  larger  vessels,  in  almost  any 
organ  by  injecting  locally  8  to  10  min- 
ims of  a  1 :  1000  solution  in  four  or 
five  times  the  same  quantity  of  saline 
solution.  Care  should  be  taken  not  to 
inject  too  large  a  dose  lest  the  un- 
toward effects  described  earlier  in  this 
article  occur.  Solutions  of  1 :  10,000 
or  even  1 :  100,000  are  quite  .sufficient 
sometimes  to  produce  a  bloodless  field 
by  causing  local  constriction  of  the 
blood-vessels. 

Toxemias  and  Bacterial  Infections. 
— This  is  a  recent  and  important  devel- 
opment of  organotherapy.  Abelous 
and  Langlois,  Charrin,  Oppenheim,  and 
others  have  laid  stress  on  the  antitoxic 
functions.  The  process  through  which 
this  protective  role  was  carried  out  by 
these  organs  being  admittedly  un- 
known, I  submitted  in  1903  and  1907 
("Internal  Secretions")  evidence  tend- 
ing to  show  that  the  adrenals  and  thy- 
roid were  the  sources  of  two  substances 
as  prominent  agents  in  the  immunizing 
process — the  thyroid  carrying  out,  we 
have  seen,  the  role  of  opsonin  (con- 
firmed by  Fassin,  Stepanoff,  and 
Marbe),  while  the  adrenal  secretion 
acted  as  amboceptor.  While  I  do  not 
regard  these  two  agents  as  the  sole 
participants  in  the  inimunizing  process, 
the  fact  remains  that  the  addition  of 
either  of  them  to  the  blood  enhances  to 
a  certain  extent  its  functional  activity. 
Especially  is  this  the  case  in  view  of 
the  fact  that  adrenal  secretion,  as  pre- 
viously stated,  serves  to  sustain  oxida- 


ANIMAL   EXTRACTS    (SAJOUS). 


767 


tion  and  tissue  metabolism.  By  doing 
so  it  activates  the  functions  of  all  tis- 
sues, including  those  concerned  with  the 
production  of  protective  sul)stances. 
The  blood  thus  finds  itself  richer  in 
these  substances  and  more  active  as  a 
germicidal  and  antitoxic  agent. 

Tn  diphtheria  the  writer  has  seen 
undoubted  improvement  in  the  general 
condition  from  2  to  3  c.c.  of  the  com- 
mercial suprarenin  solution  being  in- 
jected three  to  four  times  a  day.  The 
action  is  not  so  transient  as  after 
intravenous  use.  The  maximum  rise 
in  blood-pressure  can  be  observed  after 
one  to  two  hours,  and  the  effect  may 
last  as  long  as  seven  hours.  The  fre- 
quency of  hemorrhage  from  the  nose 
or  throat  is  not  diminished,  nor  is  the 
pulse  rate  altered.  The  injections  are 
frequently  painful ;  hence,  a  moist  dress- 
ing should  be  applied.  A  local  anemia 
may  appear  at  the  site  of  injection, 
which  may  persist  for  hours.  Ab- 
scesses, infiltrations,  or  gangrene  did 
not  occur,  nor  could  any  deleterious 
influence  upon  the  kidneys  be  observed. 
In  some  cases  a  temporary  glj^cosuria 
was  noticed,  which  may  lead  to  the  ex- 
cretion of  as  much  as  2.6  per  cent, 
sugar.  In  fatal  cases  the  arteries  were 
studied  most  carefully,  but  no  lesions 
could  be  detected.  Eckert  (Therap. 
Monats.,   Aug.,    1909). 

While  the  normal  average  of  epineph- 
rin  content  in  the  human  suprarenals 
is  about  4  mg.  (in  arteriosclerosis  it  is 
5.8  mg.  and  in  chronic  nephritis  5.79 
mg.),  in  septic  disturbances  with  low 
blood-pressure  the  average  found  was 
only  1.5  mg.  This  loss  of  epinephrin  was 
manifest  in  pneumonia,  puerperal  fever, 
meningitis,  and  other  septic  processes, 
showing  that  it  is  merely  a  general 
reaction  of  the  suprarenals  to  infec- 
tions. The  changes  in  the  suprarenals 
may  be  a  swelling  of  the  parenchyma, 
cystic  degeneration,  or  development  of 
hemorrhagic  infarcts — all  the  changes 
being  serious  and  explaining  the  dis- 
turbance or  total  arrest  of  supra- 
renal functioning  in  infectious  diseases. 
This  leads  to  an  abnormally  small  por- 


tion of  epinephrin  in  the  blood,  and  this 
is  clinically  manifested  by  a  lessened 
blood-pressure.  The  collapse  in  septic 
affections  is  probably  due  chiefly  to  the 
lessened  blood-pressure  resulting  from 
the  acute  suprarenal  insufficiency.  Gold- 
sieher  (Wiener  klin.  Woch.,  June  2, 
1910). 

Infectious  diseases  constitute  the 
principal  field  in  which  the  adrenalin 
treatment  is  of  service,  and  the  writer 
has  employed  adrenalin  successfully  in 
many  cases  of  severe  collapse  in  con- 
nection with  scarlet  fever,  pneumonia, 
and  typhoid  fever.  He  does  not  hesi- 
tate to  use  large  doses.  He  invariably 
administers  it  by  subcutaneous  injec- 
tion and  has  observed  no  after-effects. 
Kirchheim  (Miinch.  med.  Woch.,  Dec. 
20,  1910). 

Adrenalin,  injected  intravenously,  in 
saline  solution,  is  indicated  in  the  treat- 
ment of  peritonitis,  used  continuously. 
The  action  of  adrenalin  on  the  diseased 
organism  must  be  borne  in  mind.  By 
using  the  drug  in  very  dilute  solution 
weakened  systole  becomes  strengthened 
and  in  time  becomes  normal  in  force. 
The  weakened  heart  and  lowered  blood- 
pressure  of  peritonitis,  also  due  to  a 
toxic  substance,  indicate  the  same 
measure.  Holzbach  (Miinch.  med. 
Woch.,  May  23,  1911). 

One  of  the  active  principles,  supra- 
capsulin,  adrenalin,  etc.,  may  be  used 
advantageousl)''  in  infectious  diseases, 
but  to  avoid  untoward  effects  it  is  best 
given  well  diluted — 10  to  15  drops  of 
the  1 :  1000  solution  in  not  less  than  1 
dram  of  water,  administered  very 
slowly.  If  given  intravenously  it  is 
preferable  to  administer  the  saline  so- 
lution as  usual,  and  then  to  introduce 
the  needle  of  the  hypodermic  syringe 
into  the  rubber  pipe,  injecting  a  drop 
of  the  adrenal  active  principle  (prefer- 
ably supracapsulin  1 :  1000)  into  the 
stream  of  saline  solution  at  short  inter- 
vals. In  this  manner  much  more  adre- 
nal principle  can  be  introduced  with  a 
minimum  of  danger. 


768 


ANIMAL  EXTRACTS    (SAJOUS). 


The  recognition  of  the  antitoxic 
property  of  the  adrenal  active  principle 
has  recently  caused  it  to  be  employed 
as  an  antidote  in  strychnine  poison- 
ing, a  fact  pointed  out  by  Abelous 
and  Langlois  in  1898.  These  authors 
also  found  it  to  oppose  the  toxicity 
of  nicotine,  while  Oppenheim  ob- 
tained similar  results  with  phos- 
phorus. 

Exner  has  shown  that  intraperitoneal 
injections  of  adrenalin  diminish  the 
rate  of  absorption  of  strychnine  intro- 
duced into  the  stomach,  and  the  writer, 
therefore,  decided  to  try  whether  adren- 
alin given  by  the  mouth  would  exert  a 
similar  effect.  He  first  found  that 
adrenalin  could  exert  its  vasocon- 
strictor action  after  the  arteriolar  wall 
has  been  subjected  to  the  action  of 
cyanide  of  potassium,  and  then  studied 
its  effects  upon  rabbits  poisoned  by  the 
cyanide.  He  was  able  to  bring  about 
recovery  after  longer  periods  than  in 
rabbits  which  had  not  received  adren- 
alin. He  recommended  the  following 
procedure  for  cases  of  cyanide  poison- 
ing in  man.  Adrenalin  should  be  given 
immediately,  9  c.c.  (i.e.,  3  drams)  of  the 
1 :  1000  solution  diluted  to  90  c.c.  saline 
solution;  then  Martin  and  O'Brien's 
antidote  if  available.  This  consists  of 
30  c.c.  (1  ounce)  of  a  23  per  cent,  sohi- 
tion  of  ferrous  sulphate,  30  c.c.  of  5 
per  cent,  solution  of  caustic  potash,  and 
2  Gm.  (30  grains)  of  magnesia.  The 
first  two  solutions  should  be  kept  in 
hermetically  sealed  phials.  The  three 
substances  should  be  mixed  when  re- 
quired and  immediately  taken.  The 
principle  of  the  method  is  the  forma- 
tion of  Prussian  blue,  which  is  prac- 
tically innocuous.  The  stomach  should 
then  be  washed  out  and  a  further  dose 
of  about  5  c.c.  (1^  drams)  of  1:1000 
adrenalin  solution  diluted  to  SO  c.c. 
should  be  given.  A  brisk  saline  purge 
is  also  recommended,  to  be  administered 
soon  afterward.  J.  L.  Jona  (Intercol. 
Med.  Jour  of  Austral.,  July  20,  1909). 

Adrenalin  found  experimentally  to 
counteract  the  toxic  symptoms  induced 
by  strychnine  in  the  frog.     Similarly, 


if  adrenalin  and  strychnine  are  in- 
jected, guinea-pigs  will  tolerate  sev- 
eral times  the  fatal  dose  of  the  latter 
drug.  The  action  of  adrenalin  is 
actually  antagonistic  and  not  de- 
pendent on  vascular  contraction,  with 
slower  absorption,  as  some  authors 
claim,  since  other  poisons  are  not 
affected  in  their  toxicity.  The  an- 
tagonism is  very  similar  to  that 
between  atropine  and  muscarine. 
Falta  and  Svcovic  (Berl.  klin.  Woch., 
Oct.  25,  1909;  Merck's  Archives,  Jan., 
1910). 

Postoperative    Intestinal    Atony. — 

To  the  adrenals  seem  also  to  belong 
the  credit  of  offering  the  opportunity 
to  antagonize  this  disorder.  When  in 
1903  I  submitted  the  opinion  that  the 
thyroid  secretion  enhanced  the, activ- 
ity of  the  adrenals — a  view  since  sus- 
tained by  several  experimenters — and 
that  the  adrenal  secretion,-  on  the 
other  hand,  influenced  the  functional 
activity  of  the  pancreas,  pituitary 
body,  and  other  organs,  the  state- 
ment created  some  surprise.  This 
feeling  died  out,  however,  when,  three 
years  later,  Starling  termed  hormones 
a  group  of  substances  secreted  by 
various  organs  which  could  enhance 
the  functions  of  other  organs.  Pre- 
cisely as  I  had  previously  held,  these 
hormones  were  secreted,  according 
to  Starling,  by  the  organs  which  pro- 
duced them  in  the  course  of  their  nor- 
mal functions,  and  reached  the  distant 
structures  they  influenced  through 
the  intermediary  of  the  blood.  What 
I  termed  the  adrenal  system  owed  in 
great  part  its  functional  activity  to 
this  chemical  co-ordination :  the 
adrenal  secretion  being  especially 
prominent  in  the  process  owing  to 
the  function  I  attributed  to  it,  viz., 
to  sustain  oxidation  and  metabolism 
as  a  constituent)  of  the  hemoglobin 
molecule. 


ANIMAL   EXTRACTS    (SAJOUS). 


769 


Ba}-liss  and  Staiiins;' termecK^crrr//// 
a  hormone  formed  in  the  intestinal 
mucous  memlirane  under  the  inlluence 
of  the  hydrochloric  acid  from  the 
stomach,  which  is  the  chemical  ex- 
citant of  the  pancreatic  secretion. 
Now,  from  my  viewpoint,  this  is  not 
a  specific  excitant ;  I  showed  in  1907 
(vol.  ii,  "Internal  Secretions,"  p. 
861)  that  it  presented  several  of  the 
properties  of  adrenal  extractives.  We 
are  dealing-,  therefore,  not  with  a  local 
product,  but  with  a  component  of  all 
tissues  (being  as  such  what  Starling 
has  termed  a  "mamma  hormone"), 
and  which  when  present  in  unusual 
quantities  in  any  organ  is  capable  of 
enhancing  correspondingly  its  func- 
tional activity  owing  to  its  influence 
on  local  oxidation  and  metabolism. 

Another  hormone  has  been  ob- 
tained from  the  gastric  mucosa  by 
Dohon,  Marxer,  and  Zuelzer  (Berl. 
klin.  Woch.,  Nu.  46,  1908),  which  was 
found  to  enhance  intestinal  peristal- 
sis. But  inasmuch  as  it  is  (from  my 
viewpoint)  a  ubiquitous  component 
of  all  tissues,  and  the  difficulty  of 
collecting  it  during  digestion  being- 
obvious,  search  for  it  elsewhere  sug- 
gested itself.  It  was  found  in  ample 
quantities  in  the  spleen — that  junk- 
shop  in  which  red  corpuscles  (which, 
as  I  suggested  in  1903,  are  the  com- 
mon carriers  of  the  adrenal  principle) 
are  broken  up  along  with  other  cells. 
That  the  splenic  hormone  referred  to 
is  not  purely  the  adrenalin-laden  al- 
buminous constituent  of  the  hemo- 
globin derived  from  red  corpuscles 
is  self-evident,  since  leucocytes  with 
their  nucleoproteid  granulations, 
their  trypsin-like  cytase,  and  other 
ferments  are  also  broken  up  in  the 
spleen.  The  fact  remains,  however, 
that  this  splenic  hormone  specifically 


stimulates  intestinal  peristalsis  to  a 
degree  so  remarkable  experimentally 
that  it  may  be  readily  seen  in  the  ex- 
posed intestine  of  experimental  ani- 
mals ten  tO'  fifteen  minutes  after  an 
intravenous  injection. 

The  applications  of  this  peristaltic 
hormonei  in  surgery  are  mainly  in 
those  conditions  of  intestinal  paresis 
following  operations  on  the  intestine, 
and  particularly  where  purgatives, 
castor  oil  included,  bring  on  no  re- 
sults. It  is  also  indicated  in  all  forms 
of  stubborn  constipation  due  to  intes- 
tinal atony. 

Miscellaneous  Disorders. —  The 
foregoing  disorders  may  be  said  to  rep- 
resent those  in  which  adrenal  prepara- 
tions are  more  effective  than  any  other 
preparation  at  our  disposal.  There  are 
several  others,  however,  in  which  they 
will  probably  prove  of  considerable 
"value,  when  sufficient  trial  of  them  in 
practice  will  have  warranted  a  final 
pronouncement.     These  are  : — 

Hemorrhage  from  the  pharyngeal, 
esophageal,  gastric,  or  intestinal  mucous 
membrane.  Here  the  mastication  of 
adrenal  substance  or  the  use  of  pow- 
dered adrenal  substance  in  5-grain 
capsules  arrests  the  flow,  by  causing 
active  metabolism  in  the  muscular  ele- 
ments of  the  arterioles  of  the  mucosa 
and  constriction  of  these  vessels.  The 
active  principle,  epinephrin,  supracap- 
sulin,  etc.,  has  also  been  given  by  the 
mouth  in  10-  to  15-  drop  doses. 

To  avoid  hemorrhage  during  the  re- 
moval of  placental  rests  after  abortion 
the  writer  exposes  the  cervix  and  prac- 
tises deep  injection  of  the  following 
solution  into  several  points  of  the  cer- 
vical tissue,— either  1  c.c.  of  1  per  cent, 
or  2  c.c.  of  ^  per  cent,  cocaine  solu- 
tion to  which  3  drops  of  1 :  1000  adren- 
alin solution  has  been  added.  After 
waiting   ten   minutes,   the   operation    of 


1—49 


770 


ANIMAL   EXTRACTS    (SAJOUS). 


emptying  the  uterus  is  practically  blood- 
less and  the  organ  is  firmly  contracted, 
though  patency  of  the  cervix  remains. 
O.  Crasser  (Zentralbl.  f.  Gynak.,  June 
19,  1909). 

The  writer  has  seen  within  the  past 
year  5  cases  of  vicarious  hemorrhage, 
1  of  the  rectum,  from  the  inner  can- 
thus  of  the  nose,  etc.,  in  which  he  pre- 
scribed the  suprarenal  extract — adren- 
alin 1 :  1000,  giving  15  drops  every 
three  hours  until  it  ceased — and  secured 
prompt  relief.  J.  W.  Irwin  (Med. 
Brief,  Aug.,  1911). 

Sthenic  cardiac  disorders  with  dila- 
tation of  the  right  ventricle,  dyspnea, 
and  possibly  cyanosis  and  edema,  ow- 
ing to  the  direct  action  of  the  adrenal 
principle  on  the  right  ventricle  and 
improved  oxidation  and  metabolism 
in  the  cardiovascular  muscles  and 
the  tissues  at  large.  Tablets  of  from 
%  to  1  grain  of  the  desiccated  gland 
can  be  taken  after  meals. 

Asthma. — To  arrest  the  paroxysms, 
by  augmenting  the  pulmonary  and  tis- 
sue intake  of  oxygen  and  the  cardio- 
vascular propulsion  of  arterial  blood. 
From  5  to  10  minims  of  the  1 :  1000 
solution  of  suprarenalin  or  adrenalin  in 
1  dram  of  saline  solution  should  be  in- 
jected hypodermically,  massaging  the 
part  so  as  to  insure  absorption  of  the 
solution. 

Five  cases  in  which  remarkable  bene- 
fit was  obtained  from  adrenalin  in 
acute  attacks  of  asthma.  No  evil 
effects  were  observed,  even  when  the 
adrenalin  was  injected  a  number  of 
times.  The  action  is  analogous  to 
that  of  atropine  on  the  vagus,  al- 
though the  adrenalin  acts  on  the 
sympathetic.  Jagic  (Berl.  klin.  Woch., 
March  29,  1909). 

Effusions. — To  prevent  the  recur- 
rence of  serous  effusions  in  the  pleura, 
the  peritoneum,  the  tunica  vaginalis, 
etc.,  after  aspiration,  by  reducing  the 
permeability  of  the  local  capillaries  and 


restoring  the  circulatory  equilibrium. 
From  8  minims  to  2  drams  (according 
to  the  size  of  the  cavity)  of  supraren- 
alin or  adrenalin,  in  four  times  the 
quantity  of  saline  solution,  should  be 
injected  into  the  cavity. 

Disorders  of  Pregnancy  and  Par- 
turition.— The  most  useful  employ- 
ment of  adrenal  preparations  in  dis- 
orders of  this  class  is  in  obstinate 
vomiting  of  pregnancy.  This  was 
suggested  by  the  frequency  and  ob- 
stinacy of  vomiting  in  Addison's  dis- 
ease and  the  beneficial  influence  of 
adrenal  gland  over  this  symptom.  The 
benefit  is  probably  due  to  the  more 
actiA^e  destruction  of  toxic  wastes — 
which  are  increased  during  preg- 
nancy owing  to  the  presence  of  the 
fetus — a  function  in  which  we  have 
seen  the  adrenals  take  part. 

Very  severe  case  in  which  all  other 
methods  of  treatment,  hygienic,  psychic, 
and  medicinal,  had  been  tried  without 
avail.  Believing  that  the  insufficiency 
of  the  suprarenal  capsules  might  play 
an  important  part  in  this  condition 
of  autointoxication  in  pregnancy,  the 
writer  administered  to  the  patient  a 
preparation  which  comprised  all  the 
substances  contained  in  the  suprarenal 
capsules,  using  tabloids  of  suprarenal 
capsule.  An  immediate  amelioration  of 
symptoms  was  noticed,  and  in  two 
days'  time  the  vomiting  had  stopped 
entirely.  The  patient  continued  well  at 
the  time  of  writing,  taking  1  tabloid 
each  day.  T.  Silvestri  (La  Riforma 
Medica;  Med.  Record,  Sept.  11,  1909). 

Severe  case  of  hyperemesis  gravi- 
darum of  more  than  two  months' 
duration  treated  with  marked  success 
by  means  of  adrenalin  in  small  doses. 
Various  remedies  had  been  tried,  and 
artificially  induced  labor  was  seriously 
contemplated.  In  whatever  way  the 
drug  acts — whether  by  neutralizing  the 
toxins  produced  in  pregnancy,  by  toning 
up  the  nervous  and  muscular  system, 
as  a  stimulant  of  tissue  change,  or  as  a 


ANIMAL   EXTRACTS    (SAJOUS). 


771 


regulator  of  the  vasomotor  system,  or 
in  any  of  the  other  methods  which 
have  been  theoretically  suggested — the 
author  is  convinced  of  the  great  thera- 
peutic value  of  adrenal  principle  in  the 
obstinate  vomiting  of  this  class  of 
cases.  S.  Rebaudi  (Gazz.  degli  Osped. ; 
Zentralbl.  f.  Gynak.,  Nu.  44,  1909). 

Cancer, — The  fact  that  the  cancer- 
ous grov^^ths  in  mice  and  rats  had 
been  caused  to  disappear  by  the  injec- 
tion of  the  active  principle  into  these 
growths  suggested  that  the  latter  might 
also  prove  efificacious  in  man.  About 
all  that  can  be  said  for  the  present  is 
that  the  results  warrant  further  trial. 

The  writer  reports  experiments  on 
animals  carried  out  in  the  laboratory 
for  cancer  research  under  Professor 
Lewin.  The  injections  were  made  into 
the  growth.  Having  observed  acci- 
dentally that  under  injections  of  very 
small  quantities  of  adrenalin  undoubted 
carcinomatous  as  well  as  sarcomatous 
tumors  in  mice  and  rats  (which  came 
from  Ehrlich's  Institute)  had  com- 
pletely disappeared,  he  inoculated  large 
series  of  animals  with  cancerous  and 
sarcomatous  material  and  treated  imme- 
diately afterward  with  adrenalin,  while 
the  control  animals  were  not  treated. 
After  a  few  weeks  the  tumors  of  the 
animals  not  treated  increased  rapidly, 
while  the  tumors  of  the  animals  treated 
with  adrenalin  grew  scarcely  to  the  size 
of  a  pea  and  finally  disappeared  alto- 
gether. In  100  of  these  animals  a 
recurrence  was  observed  only  twice  in 
the  course  of  a  few  months. 

Of  course,  there  are  undeniable  dif- 
ferences between  the  malignant  tu- 
mors of  mice  and  men,  but  there  was, 
at  least,  a  possibility  that  human 
tumors  could  be  influenced  in  a 
similar  way.  Reicher  (Deut.  med. 
Wqch.,  Nu.  22,  1910). 

Second  series  of  experiments  in  the 
Konig  Charite  on  private  patients  on  a 
larger  scale,  based  on  the  foregoing 
experiments  in  animals.  The  writer 
gave  to  men  an  average  of  0.2  to  0.3 
Cm.  to  begin  with  and  increased  up  to 


1  Gm.  of  the  original  solutions  of  ad- 
renalin, selecting  cases  which  did  not 
suffer  from  bad  heart  disease  or  cal- 
cification of  arteries.  The  best  results 
were  obtained  in  a  boy  of  12  years  who 
suffered  from  sarcoma  of  the  vertex. 
Within  three  and  a  half  weeks  the 
tumor  was  reduced  to  one-third  of  its 
size.  The  remaining  third  was  made  to 
disappear  under  the  Christian  Muller 
method  of  X-rays  and  high  frequency 
combined.  Since  six  months  the  tumor 
has  undergone  complete  retrogression ; 
no  recurrence  has  occurred. 

The  writer  also  treated  several  cases 
of  malignant  lymphoma.  These  were 
mostly  patients  suffering  from  medias- 
tinal tumors  and  internal  metastatic 
growths,  so  that  he  could  only  see 
whether  the  visible  tumors  were  de- 
creasing under  treatment.  As  a  rule, 
he  succeeded  in  reducing  them  to  about 
half  or  one-third  of  their  size  during 
the  time  the  patients  were  in  the  hos- 
pital. But,  of  course,  life  was  not  pro- 
longed in  these  cases. 

He  has  since  tried  to  treat  other  in- 
operable tumors,  among  others  a  mel- 
anosarcoma,  which  was  identified  as 
such  under  the  microscope.  It  was  a 
metastasis  in  the  groin  which  occurred 
one  and  a  half  years  after  excision  of 
the  primary  tumor  on  the  dorsum  of 
the  foot.  Within  one  and  a  half 
months  it  had  increased  to  the  size  of 
of  a  man's  fist.  In  three  months  he 
was  able  to  reduce  its  size  very  little, 
but,  at  least,  it  has  become  stationary, 
while  before  it  was  growing  very 
rapidly.  It  is  remarkable  that  during 
the  treatments  the  patients  increased 
much  in  weight — up  to  14  pounds  in  his 
series.  There  must  be  a  constant 
anomaly  of  metabolism  somewhere. 
Reicher  (Berl.  klin.  Woch.,  Nu.  20, 
1911). 

[The  last  remark  is  suggestive  in  view  of 
the  explanation  of  the  function  of  the  adre- 
nal secretion  I  have  submitted,  viz.,  that  it 
governs  metabolism  and  nutrition,  as 
shown  in  these'  cases  by  the  marked  in- 
crease in  weight.     C.  E.  de  M.  S.] 

The  desensitizing  of  the  skin  by 
means  of  adrenalin  permits  the  use  of 


772 


ANIMAL   EXTRACTS    (SAJOUS). 


nearly  double  the  dose  of  the  X-rays 
for    a    period    of     from     fourteen    to 
eighteen    days.      The    most    important 
indication     for     this     method     is     the 
treatment    of    malignant    tumors    sit- 
uated   subcutaneously.      Reicher    and 
Lenz   (Miinch.  med.  Woch.,  June  13, 
1911). 
Osteomalacia. — In  osteomalacia  the 
adrenal  preparations  find  a  normal  in- 
dication in  view  of  their  stimulating  in- 
fluence on  metabolism  and,   therefore, 
general  nutrition,  in  which  the  osseous 
system    must   normally   partake.     This 
beneficial  process   is   further  enhanced 
by  the  fact  that  the  thyroid  apparatus 
is   itself   stimulated   through   the   same 
cause,   and   that  the  thyroid   secretion, 
as   shown  by   Macallum,    Parhon,   and 
others,  actively  promotes  calcium  me- 
tabolism. 

Case  of  non-puerperal  osteomalacia 
treated  with  adrenalin.  Slight  im- 
provement was  evident  about  the  sixth 
injection,  but  it  proved  transient,  and 
recurrence  of  severe  symptoms  com- 
pelled castration,  which  proved  promptly 
successful.  One  ovary  was  found  in 
cystic  degeneration ;  the  other  was  en- 
larged and  adherent.  The  details  of 
22  other  reported  cases  of  osteomalacia 
treated  with  adrenalin  have  shown 
that  in  each  of  the  14  cases  in  which 
improvement  was  observed  a  turn  for 
the  better  was  evident  after  the  first  or 
second  injection.  S.  Stocker,  Jr.  (Cor- 
respondenz-Blatt  f.  Schweizer  Aerzte, 
July  1,  1909). 

Six  cases  of  osteomalacia  treated  by 
the  injection  of  adrenalin,  employing  a 
solution  of  1 :  1000.  Injections  were 
made  daily  in  the  subcutaneous  tissue 
of  the  abdominal  wall  '  under  strict 
antiseptic  precautions.  The  tempera- 
.  ture  and  pulse  of  the  patient  and 
her  blood  tension  were  observed  and 
recorded  daily.  The  doses  varied  from 
0.5  to  1  c.c.  Although  the  injections 
were  somewhat  painful,  no  local  re- 
action followed.  Some  of  the  patients 
showed  decided  reaction  in  the  redness 
and  injection  of  the  face,  with  altered 


conditions  in  the  pupil.  Most  of  the 
patients  received  40  or  more  injections. 
Considerable  improvement  followed  this 
treatment.  Englander  (Zentralbl.  f. 
Gyniik.,  Nu.  13,  1909). 

Since  Bossi  (1907)  used  adrenalin  in 
the  treatment  of  osteomalacia,  some 
20  cases  have  been  reported.  The 
writer  calls  attention  to  the  case  of  a 
woman  38  years  old  in  which  the  ad- 
renalin showed  excellent  results  not 
only  in  relieving  the  symptoms,  but 
healing  the  bone  and  straightening 
of  the  deformity,  while  causing  dis- 
appearance of  pain  and  return  of 
function.  The  treatment  consisted 
of  injections  of  1  c.c.  of  a  100  per 
cent,  solution  of  adrenalin  hydro- 
chloride given  every  second  day  for 
three  months.  After  a  short  rest  the 
injections  were  given  every  third  day. 
When  the  pains  returned  the  injec- 
tions were  repeated  every  second 
day.  The  favorable  results  were 
manifested  only  after  the  thirtieth  in- 
jection. Leon  Bernard  (Presse  med., 
Nov.  20,  1909). 

Bossi's  experiments,  i.e.,  removal  of 
the  adrenals  in  pregnant  animals,  were 
repeated  by  the  writer  to  determine 
whether  any  tendency  to  osteomalacia 
could  be  detected  afterward.  He  ex- 
perimented on  rabbits  and  guinea-pigs 
and  was  unable  to  discover  evidences 
suggesting  any  such  influence  on  the 
skeleton  from  unilateral  capsulectomy. 
The  animals  all  aborted,  however,  in 
from  nine  to  thirty  days;  in  2  the 
abortion  was  internal,  and  the  embryos 
were  absorbed.  This  could  not  have 
been  the  result  of  the  operative  trauma, 
as  the  animals  had  all  recovered  com- 
pletely from  this  before  the  abor- 
tion occurred.  No  appreciable  morbid 
changes  were  found  in  the  ovaries  of 
the  animals.  Silvestri  (Riforma  Med- 
ica,  Aug.  23,  1909). 

Case  of  osteomalacia  in  which 
symptoms  of  tetany  were  induced  by 
the  injection  of  adrenalin.  The  writer 
suggests  that  it  would  be  well  to  make 
thorough  examination  of  the  thyroid 
gland,  the  hypophysis,  and  the  supra- 
renal capsules  in  every  case  of  osteo- 


ANIMAL    EXTRACTS    (SAJOUS). 


771 


malaria  that  comes  to  autopsy.     Marek 
(WicMicr  klin.  Woch.,  May  4,   1911). 

LOCAL  USE.— To  check  hemor- 
rhage from  wounds,  suprarenalin  or 
adrenalin  can  be  used  in  various  or- 
gans. 

Bates,  Dor,  and  many  other  oph- 
thalmologists have  introduced  the  lo- 
cal application  of  a  weak  solution 
to  the  conjunctiva  to  produce  a  blood- 
less field,  and  also  to  enhance  the 
local  effects  of  cocaine,  atropine,  es- 
erine,  and  other  agents  used  in  the 
eye. 

Instillations  of  4  to  5  drops  of  the 
1 :  1000  solution  of  adrenalin  or  sub- 
conjunctival injections  of  a  smaller 
quantity  causes  a  primary  reduction, 
followed  by  a  marked  increase  in  ten- 
sion. Subsequently  there  is  a  secondary 
reduction  of  tension.  These  changes 
are  observed  in  normal  as  well  as 
glaucomatous  eyes.  The  reaction  in 
normal  eyes  is  not  very  great,  but  in 
glaucomatous  eyes  it  is  quite  marked. 
In  normal  eyes,  the  effect  of  the  adren- 
alin passes  away  in  a  few  hours, 
whereas  in  glaucomatous  eyes  the  effect 
continues  for  several  days. 

In  a  certain  number  of  cases  of 
glaucoma  the  adrenalin  produced  a 
lowering  of  tension,  whereas  in  others 
it  caused  attacks  of  acute  exacerbation. 
Repeated  instillations  in  normal  eyes 
are  apparently  without  much  effect,  but 
in  glaucomatous  eyes  there  is  a  marked 
increase  in  tension  after  the  final  in- 
stillation. The  result  of  the  combined 
use  of  eserine  and  adrenalin  on  tension 
indicate  the  two  opposing  forces  are  at 
work.  Therefore,  in  eyes  that  have  a 
predisposition  to  glaucoma  it  is  advis- 
able to  combine  eserine  with  the  adren- 
alin. J.  Rubert  (Zeit.  f.  Augenheilk., 
Bd.  xxi,  S.  97,  224,  1909). 

In  50  cases  of  conjunctival  hyper- 
emia from  causes  varying  in  nature 
from  simple  congestion  due  to  eye- 
strain to  the  most  severe  types  of 
conjunctivitis,  a  single  drop  of  ad- 
renalin chloride  solution,  1 :  5000,  in 
the    conjunctival    sac    almost    imme- 


diately caused  a  Ijlanching  of  the 
membrane,  commencing  in  about  ten 
seconds,  and  reaching  a  maximum 
in  from  five  to  ten  minutes,  the  effect 
lasting  from  one-half  to  two  hours, 
according  to  the  nature  of  the  case. 
The  blanching  effect  may  be  obtained 
by  even  a  solution  of  from  1 :  12,000 
to  1  :  10,000  in  from  thirty  seconds  to 
two  minutes.  A  solution  of  1 :  2000 
was  found  to  give  the  best  results  in 
operative  work  upon  the  eye,  causing 
no  irritation  that  could  be  noted  upon 
close  observation.  A  2  per  cent,  solu- 
tion of  cocaine  hydrochloride  was  used 
ten  minutes  prior  to  the  instillation  of 
the  adrenalin,  when  operation  was  con- 
templated, in  order  that  the  effect  of  the 
anesthetic  might  not  be  interfered  with, 
thus  insuring  a  painless  and  almost 
bloodless  result.  MacFarlane  (Can. 
Practitioner,  June,  1909). 

This  applies  as  well  to  the  local  use 
of  adrenal  extractives  in  the  nose, 
pharynx,  and  larynx,  a  weak  solution 
of  cocaine,.  4  per  cent.,  for  example, 
acquiring  the  power  of  15  to  20  per 
cent,  solution,  both  as  anesthetic  and 
styptic.  Combined  with  B-eucaine 
(5  c.c.  of  1  per  cent,  solution),  supra- 
renalin, or  adrenalin,  3  drops  of  the 
1 :  1000  suffice  when  injected  in  small 
quantities  into  the  tissues,  or,  applied 
locally  to  mucous  membranes,  are 
quite  efifective  for  operations  in  al- 
most any  region,  including  the 
urethra.  The  cocaine  and  adrenalin 
solution  referred  to  above  is  equally 
effective,  the  operation  being  performed 
after  three  or  four  minutes.  These  so- 
lutions are  extensively  used,  especially 
for  dental,  uterine,  rectal,  and  urethral 
operations. 

Hemorrhoids. — Bouchard  intro- 
duced the  use  of  tampons  soaked  in 
adrenal  preparations  for  the  treatment 
of  this  condition.  In  external  piles,  es- 
pecially If  there  is  great  distention  and 
hemorrhage,  20  drops  of  suprarenalin  in 


774 


ANIMAL   EXTRACTS    (SAJOUS). 


2  drams  of  saline  solution  applied  with 
a  compress  relieve  greatly  the  conges- 
tion and  the  pain.  A  small  quantity  of 
cocaine  enhances  these  beneficial  ef- 
fects. 

Adrenalin  applied  to  the  skin  is 
rapidly  absorbed  and  acts  on  the  vessels 
in  the  region.  Durable  vasoconstriction 
is  obtained  by  a  moderate,  graduated 
application  of  the  adrenalin,  renewed 
according  to  the  effects  produced.  Too 
large  a  dose,  at  first,  paralyzes  the 
reaction.  Hemorrhoids  are  benefited 
when  moderate  and  recent,  unless  they 
are  the  result  of  portal  hypertension. 
The  measure  may  also  fail  on  account 
of  sclerosis  and  paresis  of  the  walls  of 
the  vessels.  The  effects  of  the  adren- 
alin are  similar  to  those  of  constriction 
hyperemia.  When  applied  locally  it  re- 
inforces the  local  defenses  without 
waiting  for  general  reactions,  the  out- 
come of  which  it  is  impossible  to  fore- 
see. The  adrenalin  is  able  to  act  in 
.  the  depths  of  the  tissues  and  to  aid 
their  defensive  efforts,  or  the  adrenalin 
may  arouse  them  to  more  effective 
resistance.  Sardon  (Annales  gen.  de 
med.,  Paris,  Feb.,  1909). 

Neuralgia,    Sciatica,    and    Neuritis. 

— To  subdue  and  sometimes  arrest  pain 
in  these  disorders,  by  causing  ischemia 
of  the  hyperemic  and,  therefore,  over- 
sensitive nerves.  One  to  2  minims  of 
a  1 :  1000  suprarenalin  or  adrenalin 
ointment  applied  by  inunction  over  the 
painful  area. 

Cutaneous  Disorders. — Local  appli- 
cations of  the  1 :  1000  solutions  of  su- 
pracapsulin,  adrenalin,  etc.,  may  be 
used  advantageously  to  assuage  pain 
and  counteract  inflammation,  which 
they  do  by  causing  constriction  of 
the  arterioles.  Among  the  conditions 
in  which  they  have  proven  useful  are 
toxic  erythema,  urticaria,  acne,  sun- 
burn, bee-sting,  eczema,  chilblains,  ar- 
thralgia, arthritis,  varicose  veins, 
burns,  and  X-ray  dermatitis. 


Personal  case  in  which  adrenalin 
solution  was  used  with  great  benefit. 
In  one  of  these,  a  woman  spilled  the 
contents  of  a  kettle  of  hot  grease  over 
her  forearm,  causing  what  looked  to 
be  a  serious  burn.  This  was  dressed 
with  a  mixture  of  olive  oil,  2  ounces; 
bismuth  subnitrate,  2  drams,  and  a  few 
drops  of  carbolic  acid  and  adrenal  solu- 
tion. Within  twelve  hours  there  was 
very  little  redness,  and  the  following 
night  the  patient  was  able  to  attend  a 
dance  in  a  short-sleeved  dress.  Another 
case  was  that  of  a  man  operating  a 
gasolene  engine.  Owing  to  the  fact 
that  his  engine  was  not  acting  properly, 
he  removed  the  spark-plug  and  at- 
tempted to  blow  the  soot  away  from 
the  borders  of  the  plug  aperture,  when 
the  engine  back-fired  and  burned  his 
face  to  quite  a  considerable  extent.  An 
application  similar  to  the  above  relieved 
the  acute  symptoms  within  a  few  hours, 
and  the  man  was  able  to  resume  his 
work  the  following  morning.  The 
adrenal  solution  almost  immediately  re- 
lieves the  congestion  and  overcomes  the 
tendency  to  secondary  inflammation.  G. 
L.  Servoss  (Amer.  Jour.  Clin.  Med., 
May,  1909). 

PITUITARY  ORGANOTHER- 
APY. 

"We  may  assume,"  wrote  Schafer 
in  1898,  in  a  review  of  the  investiga- 
tions on  the  physiological  role  of  this 
organ,  "that  the  pituitary  body  fur- 
nishes to  the  blood  an  internal  secre- 
tion, and  that  this  internal  secretion 
tends  to  increase  the  contraction  of  the 
heart  and  arteries,  and  perhaps  influ- 
ences nutrition  of  some  of  the  tissues, 
especially  bone  and  the  tissues  of  the 
nervous  system."  Howell  showed,  how- 
ever, that  of  the  two  lobes  of  the  organ 
extract  of  the  anterior  lobe  produced 
no  effect — a  fact  confirmed  by  several 
investigators — and  that  the  main  action 
of  extracts  of  the  posterior  lobe  was 
to  slow  the  heart  and  raise  the  blood- 
pressure.      Schafer  and   Vincent   then 


ANIMAL   EXTRACTS    (SAJOUS). 


775 


concluded,  after  experiments,  that  the 
pituitary  contained  both  a  pressor  and 
a  depressor  substance. 

Doses  of  IS  to  20  minims  of  pituitrin 
produce  a  perceptible  increase  in  the 
blood-pressure  in  from  four  to  twenty 
minutes,  and  maintain  it  from  twenty- 
minutes  to  an  hour  or  even  longer, 
differing  in  this  respect  from  adrenalin, 
in  which  the  effect  is  far  more  tran- 
sient. There  is  a  coincident  change  in 
the  pulse  rate,  diminishing  as  the  blood- 
"  pressure  increases  and  increasing  as  it 
falls.  However,  this  change  is  more 
gradual,  both  in  its  downward  course 
and  its  return  to  normal. 

The  rise  in  blood-pressure  varies 
from  8  to  38  mm.,  while  the  pulse  rate 
falls  from  4  to  17  beats  per  minute. 
No  untoward  effects  were  noted  in  any 
of  the  cases  in  which  larger  or  repeated 
doses  were  administered.  The  inhibi- 
tory influence  upon  the  pulse  is  more 
lasting  than  the  influence  upon  the 
blood-pressure.  H.  G.  Beck  and  J.  J. 
O'Malley    (Amer.   Med.,   Oct.,    1909). 

The  anterior  lobe  also  contains  a 
pressor  substance,  but  its  action  is  usu- 
ally masked  by  excessive  amount  of 
depressor  substance  present.  By  first 
removing  the  depressor  substance  by 
extracting  with  alcohol,  it  was  possible 
to  demonstrate  a  pressor  substance  in 
the  anterior  lobe,  chiefly  in  that  portion 
adjacent  to  the  cleft  and  which  his- 
tologically is  pars  intermedia.  Both 
portions  of  the  posterior  lobe  contain 
a  pressor  substance.  Cysts  of  the  pars 
intermedia  and  colloid  from  the  cleft, 
the  secretion  from  the  pars  intermedia, 
ha\;e  a  distinct  pressor  effect.  It  is 
scarcely  probable  that  the  tissues  so 
entirely  different  as  the  pars  intermedia 
and  pars  nervosa  should  contain  a 
pressor  substance.  J.  L.  Miller,  D.  D. 
Lewis.  S.  A.  Matthews  (Boston  Med. 
and  Surg.  Jour.,  July  6,  1911). 

The  pressor  substance  was  looked 
upon  as  resembling  that  of  adrenal  ex- 
tracts, its  application  to  mucous  mem- 
branes producing  blanching,  as  is  the 
case    with    adrenalin.      With    Herring, 


Schafer  then  found  that  pituitary  ex- 
tract was  endowed  with  powerful  di- 
uretic properties,  and  that  it  produced, 
dilatation  of  the  organ.  Finally,  Her- 
ring advanced  t'le  theory  that  the  se- 
cretion was  formed  in  the  anterior  lobe 
and  completed  in  the  posterior  lobe, 
and  that  it  then  passed  into  the  third 
ventricle,  to  mix  therein  with  the  cere- 
brospinal fluid. 

Two  conditions,  one  due  to  a  patho- 
logically increased  activity  of  the  pars 
anterior  of  the  hypophysis  (hyper- 
pituitarism), the  other  to  a  diminished 
activity  of  the  same  epithelial  struc- 
ture (hypopituitarism),  seem  capable  of 
clinical  distinction.  The  former  ex- 
presses itself  chiefly  as  a  process  of 
overgrowth — gigantism  when  originat- 
ing in  youth,  acromegaly  when  orig- 
inating in  adult  life.  The  latter  ex- 
presses itself  chiefly  as  an  excessive, 
often  a  rapid  deposition  of  fat  with 
persistence  of  infantile  sexual  charac- 
teristics when  the  process  dates  from 
youth,  and  a  tendency  toward  a  loss 
of  the  acquired  signs  of  adolescence 
when  it  first  appears  in  adult  life. 
Experimental  observations  show  not 
only  that  the  anterior  lobe  of  the  hy- 
pophysis is  a  structure  of  such  impor- 
tance that  a  condition  of  apituitarism 
is  incompatible  with  the  long  mainte- 
nance of  life,  but  also  that  its  partial 
removal  leads  to  symptoms  comparable 
to  those  which  are  regarded  as  charac- 
teristic of  lessened  secretion  (hypo- 
pituitarism) in  man.  Cushing  (Jour. 
Amer.  Med.  Assoc,  July  24,  1909). 

From  my  viewpoint,  the  prevailing 
idea  that  either  lobe  of  the  pituitary 
is  a  secreting  organ  was  based  on  an 
assumption  at  the  start,  and  has  been 
perpetuated  as  such.  The  effects  of  its 
extracts  are  those  of  the  adrenal  prin- 
ciple which  the  posterior  pituitary  con- 
tains; not  only  does  the  pressor  sub- 
stance give  the  actions  of  chromaffin 
substance,  due  to  the  presence  of  the 
adrenal  principle,  but  it  produces  the 


776 


ANIMAL   EXTRACTS    (SAJOUS). 


same  effects.  The  functions  I  have  at- 
tributed to  the  pituitary  are  totally  dif- 
ferent; but  as  they  do  not  bear  in  any 
way  upon  the  valuable  therapeutic  ef- 
fects of  this  organ,  they  need  not  be 
described  in  the  present  connection.  As 
I  view  it,  therefore,  pituitary  prepara- 
tions merely  afford  an  additional  and 
efficacious  way  of  administering  adre- 
nal preparations.  Being  bound  up  in 
organic  combination, the  adrenal  prin- 
ciple acts  with  less  violence,  owing, 
probably,  to  the  fact  that  even  in  the 
tissues  the  product  injected  is  decom- 
posed very  slowly. 

Herring's  view  that  the  colloid  fluid 
passes  upward  is  quite  warranted;  but 
this  does  not  prove  in  the  least  that  it 
is  a  true  secretion.  In  fact.  Dr.  Cush- 
ing's  own  text  suggests  the  contrary. 
Since  the  blood-pressure-raising  sub- 
stance is  "confined,  as  Howell  has 
proved,  to  the  posterior  lobe,"  why  is  it 
that,  as  Dr.  Gushing  says,  "after  this 
portion  of  the  gland  has  been  removed, 
there  is  no  apparent  disturbance  with 
the  physiologic  balance  of  the  body?" 
Everyone  knows  that  removal  of  the 
adrenals  or  of  the  thyroid,  which  pro- 
duce true  secretions,  causes  marked 
and  even  fatal  disturbances.  Again,  the 
anterior  pituitary  is  regarded  by  Dr. 
Gushing  as  the  original  source  of  this 
secretion;  why  is  it  that  its  extracts  are 
inert?  Gan  we  consistently,  with  him, 
ascribe  acromegaly,  overgrowth,  etc., 
to  "hypersecretion,"  and  dystrophia  adi- 
posogenitalis,  Dercum's  adiposis  dolo- 
rosa, etc.,  to  "hyposecretion"  of  this 
inert  substance?  These  are  but  few  of 
the  many  features  which  the  secre- 
tion theory  does  not  meet.  G.  E. 
de  M.  Sajous  (Jour.  Amer.  Med. 
Assoc,  Aug.  21,  1909). 

.Whichever  opinion  ultimately  pre- 
vails concerning  its  physiological  ac- 
tion, the  fact  remains  that  pituitary  is  a 
valuable  remedial  agent  in  many  disor- 
ders. Its  marked  advantage  is  that  it 
sustains  the  rise  of  blood-pressure,  to 


which  it  gives  rise  much  longer  than 
does  adrenalin,  thus  being  more  re- 
liable in  shock  and  other  emergency 
cases.  It  seems  also  to  sustain  the  tem- 
perature and  the  muscular  tone,  car- 
diac, vascular,  intestinal,  and  uterine, 
longer  than  the  adrenal  active  principle. 
It  possesses  also  a  great  practical  ad- 
vantage over  adrenalin  and  other  adre- 
nal principles  in  that  it  can  be  admin- 
istered by  the  mouth  without  compro- 
mising its  effects. 

PREPARATIONS  AND  DOSE. 
— Pituitary  gland  is  available  in  drug 
stores  in  the  form  of  powder  or  tablets 
of  desiccated  gland.  The  same  prep- 
arations of  the  infundibular,  or  pos- 
terior, lobe,  which  is  the  active  one 
therapeutically,  can  also  be  obtained. 
The  dose  is  from  1  to  5  grains  three 
times  daily. 

A  product  called  "pituitrin"  by  its 
manufacturers,  in  the  form  of  a  pow- 
der, is  available  on  our  market  for  oral 
use,  the  dose  of  which  is  given  as  10 
to  30  grains  (0.66  to  2  Gm.). 

There  is  also  a  liquid  extract  of  the 
posterior  lobe,  wrongly  termed  "infun- 
dibular extract,"  the  infundibulum  be- 
ing the  pedicle  which  unites  both  lobes 
of  the  pituitary  to  the  base  of  the 
brain.  This  infundibular  extract  affects 
mucous  membranes  precisely  as  do 
adrenal  extractives,  and  should  be  ap- 
plied only  when  diluted  in  eight  or  ten 
times  the  same  quantity  of  saline  solu- 
tion. It  may  be  given  orally  in  10-  to 
30-  minim  (0.62  to  2  c.c.)  doses,  or 
intramuscularly  in  3-  to  15-  minim 
(0.2  to  0.92  c.c.)  doses. 

"Vaporole,"  a  liquid  extract  of  for- 
eign origin,  issued  in  hermetically  sealed 
containers,  is  suitable  for  intramuscu- 
lar injections ;  these  are  best  given  in 
the  ■  gluteal  region,  after  the  skin  has 
been  carefully  asepticized. 


ANIMAL   EXTRACTS    (SAJOUS). 


777 


THERAPEUTICS.  — Acromegaly. 

— The  possible  value  of  pituitary  ex- 
tracts in  tills  disease  of  the  pituitary 
has  naturally  suggested  itself,  but,  al- 
though a  few  of  the  syiuptoius,  the 
headache,  lethargy,  and  amnesia,  were 
relieved  in  some,  no  cijres  were  ob- 
tained. Analysis  of  the  cases  reported 
as  benefited  suggests  an  explanation  of 
its  mode  of  action,  however,  one  quite 
apart  from  any  functional  relationship 
with  the  organ  as  the  source  of  an  in- 
ternal secretion,  but  entirely  in  keeping 
with  the  presence  in  the  pituitary  prep- 
aration of  adrenal  secretion  in  organic 
combination.  Marinesco  observed  that 
it  was  the  extremely  violent  headaches 
that  were  relieved,  there  being  no  benefit 
otherwise,  excepting  perhaps  increased 
diuresis.  Kuh,  obtaining  no  favorable 
result,  withdrew  the  remedy,  but  the 
patient  begged  to  be  given  the  powders 
again,  having  found  his  headache  much 
more  intense  when  he  failed  to  take 
them.  The  same  observation  had  been 
recorded  by  Cyon,  the  patient,  an  obese 
child  of  12  years,  having  besides  lost 
twenty  pounds  in  weight.  What  benefit 
was  obtained  in  1  case  out  of  7  cases 
treated  by  Kinnicutt  was  also  limited 
to  the  headache  and  neuralgia.  Les- 
zynsky,  after  a  prolonged  trial  in  2 
cases,  wrote :  "While  some  published 
reports  as  to  the  efficacy  of  the  prep- 
arations of  the  sheep's  gland  have 
seemed  quite  encouraging  in  so  far  as 
the  relief  of  headache  and  of  paresthesia 
of  the  hands  is  concerned,  it  is  the 
general  consensus  of  opinion  that  it  in 
no  way  influences  the  progress  of  this 
disease." 

Still,  the  relief  of  the  headache  and 
paresthesias  indicates  some  potent  ac- 
tion. This  is  accounted  for  if  the  adre- 
nal principle  is  considered  as  the  active 
agent    of    the    pituitary    preparations. 


since,  as  Langley  has  shown,  it  is  prin- 
cij)ally  upon  the  arterioles  that  the 
adrenal  principle  acts,  a  view  which 
has  now  become  classic.  Such  being 
the  case,  the  tumor  of  the  pituitary,  or 
the  compressed  tissues  around  it,  re- 
ceive less  blood  through  their  con- 
stricted arterioles,  and  the  sensory  ter- 
minals of  the  peripheral  likewise.  The 
resulting  ischemia  of  these  tissues  thus 
accounts  for  the  diminution  of  pain — 
as  long  only  as  the  remedy  is  adminis- 
tered. 

Cardiac  Disorders. — As  shown  by 
Renon  and  Delille,  pituitary  gland 
raises  the  depressed  arterial  tension  and 
corrects  purely  functional  disorders  of 
rhythm. 

It  is  recommended  in  doses  ranging 
from  3  to  6  grains  (0.2  to  0.4  Gm.)  of 
the  whole  gland  in  myocardial  weak- 
ness, particularly  in  that  due  to  infec- 
tions when  the  blood-pressure  is  reced- 
ing, the  pulse  is  becoming  more  rapid, 
and  the  urine  scanty.  While  less  active 
than  digitalis  as  a  diuretic,  it,  neverthe- 
less, serves  a  valuable  purpose  in  this 
connection.  It  is  advantageous  in  mi- 
tral disorders  when  there  is  hyposys- 
tole  and  in  chronic  myocarditis,  par- 
ticularly that  due  to  alcoholism.  It 
is  also  useful  in  the  tachycardia  of 
certain  neuroses  and  during  meno- 
pause. These  results  have  been  con- 
firmed by  Treroitoli,  Parisot,  and 
others. 

It  is  contraindicated  in  aortic  affec- 
tions in  any  disorder  in  which  high  vas- 
cular tension  prevails,  and  where  there 
is  a  tendency  to  anginal  pains,  which  it 
tends  greatly  to  aggravate. 

Pituitary  gland  is  preferred  to  adre- 
nal preparations  and  particularly  adren- 
alin when  the  action  is  to  be  sustained, 
the  former' being  useful  in  urgent  cases. 
Renon    and    Delille,    however,    prefer 


778 


ANIMAL   EXTRACTS    (SAJOUS). 


digitalis,  and  recommend  pituitary 
gland  only  when  the  latter  fails.  Leon- 
ard Williams,  on  the  other  hand,  deems 
it  superior  to  digitalis,  strophanthus, 
strychnine,  and  other  classic  tonics  in 
what  he  terms  the  "runaway  heart  o£ 
toxic  states,"  influenza,  pneumonia, 
bronchitis,  etc.,  with  tachycardia,  but 
low  blood-pressure,  and  in  all  cases  in 
which  there  is  posttoxic  cardiac  debil- 
ity. In  these  cases — which,  from  my 
viewpoint,  are  instances  of  pure  hypoa- 
drenia — Williams  regards  pituitary 
preparations  superior  to  any  remedy 
at  our  command. 

In  heart-failure  and  shock,  it  has 
been  highly  recommended,  15  minims 
(0.92  c.c.)  of  the  extract  being  injected 
intramuscularly.  While  its  virtues 
would  seem  to  recommend  it  for  the 
perpetuation  of  the  effects  of  adrena- 
lin, .which  are,  at  best,  but  temporary, 
the  number  of  cases  in  which  it  has 
been  tried  has  been  too  limited  so  far 
to  warrant  an  opinion  as  to  its  actual 
value. 

Experimental  study  of  the  therapeutic 
value  of  infundibular  extract  in  shock, 
uterine  atony,  and  intestinal  paresis, 
conducted  by  injecting  an  extract  of  it 
into  animals  and  by  observing  the 
effect  of  the  removal  of  it  in  part  or 
wholly.  It  raises  the  blood-pressure, 
and  even  better  when  the  animal  is  in 
a  condition  of  shock  than  in  a  normal 
state.  Moreover,  it  keeps  the  pressure 
raised  for  several  hours,  whereas  the 
effect  of  adrenalin  in  this  respect  is 
but  temporary.  It  will  not  take  the 
place  of  salines,  for  on  the  latter  rests 
the  responsibility  of  maintaining  the 
improvement  produced  by  any  remedy. 
The  extract  also  causes  powerful  con- 
tractions in  the  pregnant,  puerperal,  and 
menstruating  uterus.  It  probably  acts 
better  on  an  atonic  organ  than  on  a 
normal  one.  The  remedy  can  be  em- 
ployed in  a  normal  labor.  Subinvolu- 
tion due  to  the  defective  contraction 
and  retraction  is  one  of  the  dangers  in 


Cesarean  section,  especially  if  per- 
formed before  the  onset  of  labor;  in 
such  circumstances  secretions  and  blood- 
clots  may  be  retained  and  become  in- 
fected— a  state  of  affairs  favored  by 
any  contraction  of  the  pelvis  which 
may  be  present,  for  this  condition 
leads  to  a  sagging  forward  of  a  sub- 
involuted  ^organ.  The  remedy  ought 
to  be  given,  but  rarely  before  delivery. 
For  general  post-partum  purposes  it  is 
better  than  ergot.  It  also  excites  active 
peristalsis  in  the  bowel.  There  is  little 
doubt  that  its  chief  effect  is  peripheral, 
for  if  we  place  a  rabbit's  isolated  and 
active  uterus  in  Ringer's  solution  the 
organ  contracts  violently  on  the  addi- 
tion of  a  small  quantity  of  the  extracts. 
W.  H.  Bell  (Brit.  Med.  Jour.,  Dec.  4, 
1909). 

In  3  cases  of  heart-failure  during 
anesthesia  the  writer  injected  1  c.c. 
of  a  20  per  cent,  solution  of  the  poste- 
rior lobe  of  the  pituitary  body  intra- 
muscularly. The  effect  was  almost 
immediate,  and  the  almost  impercep- 
tible pulse  soon  became  large  and  bound- 
ing. This  effect  lasted  from  twelve  to 
sixteen  hours,  and  gradually  passed  off. 
Not  only  did  the  pulse  become  larger 
in  expansion,  but  it  was  also  slowed, 
and,  whereas  it  had  been  irregular,  it 
became  regular.  This  effect  seems  due 
not  only  to  the  action  of  the  drug  on 
the  blood-vessels,  but  also  on  the  heart. 
The  injection  was  given  in  conjunction 
with  normal  saline  by  rectum.  G.  G. 
Wray  (Brit.  Med.  Jour.,  Dec.  18,  1909). 

The  benefit  which  follows  the  use  of 
pituitrin  by  intramuscular  injection 
when  the  blood-pressure  is  abnormally 
low  is  very  marked.  The  writer  recom- 
mends it  especially  for  threatened 
collapse  and  hemorrhage  after  child- 
birth. He  thinks  it  may  prove  of 
value  in  surgical  shock  and  in  acute 
febrile  states,  but  his  use  of  it  in 
these  cases  has  not  yet  been  exten- 
sive. Pituitrin  has  two  advantages 
over  adrenalin:  namely,  its  action  is 
moderate  and  prolonged.  Klotz 
(Miinch.  med.  Woch.,  May  23,  1911). 

Obstetrics. — Dale  found,  in  the 
course   of   comprehensive   experiments, 


ANIMAL  EXTRACTS    (SAJOUS). 


779 


that  (in  keeping  with  that  of  the  adre- 
nal principle)  the  action  of  extract  of 
pituitary  was  "a  direct  stimulation  of 
involuntary  muscle  without  any  rela- 
tion to  innervation."  Frohlich  and 
Frankl-Huchwart  then  ascertained  that 
it  caused  contractions  of  the  pregnant 
uterus  in  rabbits,  while  Foges  and  Hof- 
statter  resorted  to  this  property  in  so 
far  as  the  human  uterus  was  concerned 
to  check  post-partum  and  other  uterine 
hemorrhages,  the  test  including  63 
cases.  The  extract  proved  worthless 
by  the  mouth;  but  when  injected  intra- 
muscularly, marked  uterine  contraction 
appeared  within  five  minutes  and  lasted 
a  long  while  in  most  cases. 

S.  J.  Aarons  found  pituitary  'extract 
(vaporole)  superior  to  ergot  in  labor 
cases.  The  uterus  contracted  better, 
more  quickly,  and  more  persistently 
than  under  ergot.  It  should  not  be 
used,  however,  until  after  completion 
of  the  third  stage  of  labor,  with  the  pos- 
sible exception  of  certain  cases  of  pla- 
centa previa.  The  author  gives  brief 
histories  of  1 1  illustrative  cases.  Among 
these  is  one  of  placenta  praevia  in 
which,  after  version  and  expulsion  of 
the  fetus,  removal  of  the  placenta  was 
accompanied  by  profuse  hemorrhage. 
An  intra-uterine  douche  of  weak  bi- 
chloride of  mercury  at  120°  F.  (48.9° 
C.)  was  given  and  pituitary  extract  in- 
jected deeply  into  the  buttock;  after 
this,  there  was  no  further  loss  and  the 
uterus  remained  well  contracted.  Sev- 
eral cases  of  normal  labor  followed 
by  hemorrhage  or  relaxation  of  the 
uterus  in  which  the  extract  gave  good 
results  are  also  cited. 

In  63  cases  of  post-partum  hemor- 
rhage and  after  1  abortion  the  intra- 
muscular injection  of  pituitrin  (in 
doses  of  1  to  2  c.c.)  proved  superior  to 
ergotin  with  reference  to  the  intensity 
of  the  contraction  and  continuance  of 


the  excitability.  The  authors  were  en- 
abled to  note  the  effect  of  pituitrin 
particularly  in  6  cases  of  extraperi- 
toneal Cesarean  section.  "After  not 
more  than  five  minutes  one  could  see 
how  the  exposed  uterus  contracted,  in 
response  to  a  light  tactile  irritation,  to 
a  firm  ball.  The  action  continued  for 
a  long  time,  which  accounts  for  the  fact 
that  there  was  no  hemorrhage,  a  com- 
plication that  is  always  feared  in  con- 
nection with  Cesarean  section."  In 
accordance  with  their  observations,  the 
authors  are  of  the  opinion  that  there  is 
no  doubt  concerning  the  specific  effect 
of  pituitrin  upon  the  excitation  of  the 
uterus.  Foges  and  Hofstatter  (Zen- 
tralbl.  f.  Gynak.,  Nu.  46,  1910). 

Five  cases  of  insufficiency  or  ab- 
sence of  labor  pains;  from  0.6  to  1.3 
grains  of  pituitrin  were  injected  sub- 
cutaneously.  In  every  case  the  result 
was  remarkable.  Within  a  short  time 
the  action  of  the  uterus  was  normal 
and  exhibited  no  tetanic  character. 
This  was  especially  noticeable  during 
the  period  of  expulsion.  It  is  note- 
worthy that  the  writer  obtained  the 
same  effect  after  a  repetition  of  the 
pituitrin  injection  that  followed  the 
first  administration  of  the  remedy. 
The  writer  confirmed  his  clinical  ob- 
servations by  means  of  animal  experi- 
ments on  the  puerperal  uterus  of 
rabbits;  a  few  minutes  after  the 
injection  there  were  active  contrac- 
tions o£  the  uterus,  as  was  demon- 
strated by  means  of  a  delicate  scien- 
tific apparatus.  J.  Hofbauer  (Zent- 
ralbl.  f.  Gynak.,  Nu.  4,  1911). 

The  writer  has  found  pituitrin  useful 
not  only  in  endometritis,  metritis,  and 
menorrhagias  which  were,  perhaps, 
dependent  on  increased  ovarian  activ- 
ity, but  also  in  hemorrhages  caused 
by  inflammatory  diseases  of  the  ad- 
nexa,  myomata,  and  ovarian  cysts. 
He  uses  the  remedy  subcutaneously 
in  doses  of  2  or  3  c.c.  The  only  by- 
effect  noticed  was  an  occasional  uter- 
ine cramp.  Bab  (Miinch.  med.  Woch., 
July  18,  1911). 

Case  of  a  primipara  in  the  difficult 
breech    presentation    showed    signs    of 


780 


ANIMAL   EXTRACTS    (SAJOUS). 


nephritis,  ischuria,  amaurosis,  and  ana- 
sarca. No  benefit  being  derived  from 
quinine  and  ergot,  pituitary  extract  was 
injected  the  third  day  on  account  of 
persisting  ischuria  and  the  dehvery  was 
forcibly  completed  with  great  difficulty. 
After  a  few  hours  of  improvement  the 
patient  succumbed  to  the  uremia.  This 
suggests  that  pituitary  should  be  re- 
served for  uncomplicated  uterine  atony. 
Pfeifer  (Zentralbl.  f.  Gynak.,  June  3, 
1911). 

Pituitrin,  the  extract  of  the  pos- 
terior lobe,  stimulates  the  uterus  to 
contract.  The  writers  recommend  its 
use  whenever  it  becomes  necessary 
to  induce  premature  labor.  The  dose 
used  by  him  is  0.6  to  1  c.c.  (6*^  to 
IS  grains)  injected  subcutaneously 
and  repeated  as  often  as  necessary. 
During  labor,  the  pains  are  almost 
invariably  intensified  and  the  child  is 
born  without  showing  any  effects  of 
the  drug.  To  induce  labor,  as  in 
tuberculosis  and  nephritis,  repeated 
injections  are  often  necessary,  as  the 
pains  induced  at  first  are  not  always 
of  long  duration  or  sufficient  inten- 
sity. In  2  cases  labor  was  terminated 
by  the  use  of  pituitrin  alone;  in  a 
third  it  was  also  necessary  to  stretch 
the  cervix.  Even  with  advanced  ne- 
phritis, the  mothers  showed  no  unde- 
sirable after-effects  and  the  infants 
were  perfectly  normal.  R.  Stern  and 
O.  Bondy  (Berl.  klin.  Woch.,  Aug.  7, 
1911). 

In  3  cases  of  intestinal  paresis  fol- 
lowing operations  for  ovarian  cyst 
and  ectopic  gestation,  quite  prompt 
relief  was  obtained  by  injections 
of  pituitary  extract.  In  a  case  of 
subinvolution  of  the  uterus,  the  pa- 
tient suffering  from  menorrhagia,  for 
which  she  had'  recently  been  curetted 
without  result,  and  having  soft,  flabby 
tissues  and  low  blood-pressure,  Aarons 
decided  to  try  the  effect  of  repeated 
doses  of  pituitary  extract.  Six  injec- 
tions were  given  in  as  many  weeks. 
The      uterus      underwent      contraction 


from  5  to  3  inches  as  measured  by  the 
sound ;  the  general  condition  was  much 
improved,  and  had  remained  so  six 
months  after  the  treatment.  During 
the  administration  of  the  pituitary  ex- 
tract marked  polyuria  was  noted.  No 
deleterious  effects  resulted.  The  author 
suggests,  however,  that  the  use  of  the 
extract  in  subinvolution  be  limited  to 
cases  with  associated  low  blood-pres- 
sure. 

Ott  and  Scott  found  infundibulin, 
i.e.,  extract  of  the  posterior  lobe,  to  act 
as  a  powerful  galactagogue  in  the 
goat.  So  far,  however,  it  has  not  been 
tried  in  women. 

Infectious  Diseases. — In  this  gen- 
eral class  of  disorders  the  use  of  pit- 
uitary acts,  from  my  viewpoint,  and 
in  keeping  with  the  effects  of  adre- 
nal preparations,  by  enhancing  the  im- 
munizing activity  of  the  blood  and  the 
tone  of  the  cardiovascular  system. 
That  such  was  the  case  in  the  infec- 
tious diseases  in  which  it  was  tried  can 
only,  however,  be  surmised. 

Renon  and  Delille  found  that  in 
typhoid  fever  it  raised  the  blood- 
pressure,  slowed  the  pulse,  increased 
diuresis,  and  improved  the  patients  in 
general,  hastening  convalescence  no- 
ticeably. In  diphtheria,  in  which  the 
toxin  reduces  the  vascular  tension  and 
promotes  cardiac  complications,  it 
lowered  the  pulse  rate,  raised  the 
blood-pressure,  and  increased  diure- 
sis. In  erysipelas  it  seemed  to  hasten 
the  favorable  evolution  of  the  disease. 
In  pneumonia  it  raised  the  blood- 
pressure  when  this  became  low.,  but 
without  influencing  favorably  the  evo- 
lution of  the  disease.  In  broncho- 
pneumonia, however,  the  opposite 
proved  to  be  the  case,  considerable 
benefit  being  noted.  Influenza  was 
found  to  be  very  favorably  influenced. 


ANIMAL   EXTRACTS    (SAJOUS). 


781 


rapid  recovery  resulting  in  patients 
aged,  respectively,  80  and  ()3  years. 
This  was  confirmed  by  Azam,  in  the 
infectious  form.  Renon  and  Azam 
enumerate  the  phenomena  which,  in  in- 
fectious diseases,  indicate  the  need  of 
pituitary:  1,  a  fall  of  the  arterial  ten- 
sion; 2,  quickening  of  the  pulse  and, 
as  complementary  minor  phenomena, 
insomnia,  anorexia,  abnormal  sweating, 
and  heat  flushes.  Under  the  influence 
of  pituitary  there  occur:  1,  increase  of 
arterial  tension ;  2,  slowing  of  the  pulse, 
with  increase  of  power  and  amphtude ; 
3,  increased  diuresis;  4,  increase  in 
weight;  5,  hastening  of  convalescence. 

In  several  cases  of  tuberculosis 
treated  by  Renon  and  Delille,  the  re- 
sults were  not,  on  the  whole,  encour- 
as"ing.  In  a  case  of  Addison's  disease 
complicating  tuberculosis,  however, 
there  was  a  notable  rise  of  the  blood- 
pressure  and  diminution  of  the  asthe- 
nia. Trerotoli  had  already  noted  the 
beneficial  elTects  of  pituitary  body  in 
Addison's  disease — a  fact  wdiich  fur- 
ther suggests  that  the  active  agent  of 
pituitary  substance  is  its  adrenal  com- 
ponent. 

Exophthalmic  Goiter. — Renon  and 
Dehlle  obtained  considerable  improve- 
ment in  this  disease  by  the  use  of  pitui- 
tary, gland.  From  the  fourth  to  the 
fifth  day,  the  sleeplessness,  tremor,  di- 
gestive disturbance,  sweating,  and  sen- 
sation of  heat  were  considerably  les- 
sened. The  tachycardia  improved  less 
rapidly,  the  pulse  becoming  slower 
gradually  and  attaining  its  slowest  rate 
toward  the  fifteenth  day.  The  arterial 
tension  also  rose  steadily,  attaining  the 
maximum  toward  the  third  week,  fall- 
ing again  somewhat,  but  not  to  the  for- 
mer low  level.  Some  diminution  of  the 
exophthalmus  occurred,  but  the  goiter 
was  not  reduced.     The  dose  adminis- 


tered was  4/2  grains  (0.30  Gm.)  of 
the  whole  pituitary  (ox)  gland  daily, 
a  dose  which  they  deem  advisable  to  in- 
crease to  7y-i  grains  (0.50  Gm.)  in  di- 
vided doses  daily.  The  symptoms  tend 
to  return,  however,  on  discontinuing 
the  remedy.  Cases  subsequently  treated 
were  also  benefited,  but  no  cures  were 
effected. 

This  mode  of  action,  from  my  view- 
point, corresponds  precisely  with  that 
referred  to  under  the  preceding  head- 
ing. We  have  seen  that  the  main 
pathological  condition — that  to  which 
all  the  prominent  symptoms  of  exoph- 
thalmic goiter  were  due — was  a  gen- 
eral dilatation  of  the  arterioles.  Pit- 
uitary extract  causing  constriction  of 
these  vessels  as  long  as  it  is  admin- 
istered, it  oflfsets  for  the  time  the 
morbid  phenomena  enumerated.  That 
such  is  actually  the  case  was  demon- 
strated b.y  Hallion  and  Carrion,  who 
found,  experimentally,  that  pituitary 
extracts  "always  produced  their  ef- 
fects by  raising  the  arterial  tension," 
producing  at  the  same  time  "an  in- 
tense vasoconstrictor  action  upon  the 
thyroid  body."  Briefly,  we  have  here 
precisely  the  ph3^siological  action  nec- 
essary, the  vasoconstrictor  power  of 
the  adrenal  component  of  the  pitui- 
tary gland  superseding  the  vasodila- 
tor action  of  the  thyroid,  the  under- 
lying cause  of  the  disease. 

Nervous  and  Mental  Diseases  and 
Myopathies. — Renon  and  Delille  used 
pituitary  in  10  neurasthenics  in  whom 
tachycardia ;  irregular  vascular  tension, 
often  below  normal;  a  sensation  of  op- 
pression, myasthenia,  insomnia,  and 
anorexia  were  present.  In  these  cases 
3  to  5  grains  (0.2  to  0.3  Gm.)  daily 
proved  remarkably  useful,  though  no 
complete  recovery  was  noted. 

Delille  and  Vincent  obtained  a  com- 


782 


ANIMAL   EXTRACTS    (SAJOUS). 


plete  recovery  in  a  grave  case  of 
bulbospinal  myasthenia  by  the  simul- 
taneous use  of  pituitary  and  ovarian 
extracts.  Parhon  and  Urechia  and 
Leopold-Levi  and  de  Rothschild  had 
also  obtained  favorable  results  with 
pituitary  in  similar  cases.  Browning 
observed  good  effects  in  cases  of 
chorea  in  which  this  disorder  occurred 
in  conjunction  with  stunted  growth, 
as  shown  under  the  next  heading. 

In  epilepsy  it  was  tried  by  Mairet 
and  Bose,  but  only  served  to  increase 
the  number  of  attacks — a  result  to  be 
expected,  since  Spitska  has  shown  that 
these  were  due  to  abnormal  elevation 
of  the  blood-pressure.  In  some  in- 
stances it  provoked  delirium. 

Sollier  and  Chartier  tried  pituitary  in 
mental  disorders  and  found  it  useful 
in  depressive  states.  It  raised  the 
blood-pressure,  reduced  the  pulse,  sup- 
pressed profuse  sweating,  and  improved 
the  asthenia.  The  synthesis  of  percep- 
tions and  the  association  of  ideas  were 
improved,  and  mental  operations  were 
incited  more  promptly. 

Stunted  Growth  and  Imbecility. — 
In  a  case  in  which  a  child  of  3  years 
had  shown  the  evidences  of  hypothy- 
roidia  with  idiocy  sufficiently  to  sug- 
gest the  use  of  thyroid,  Leopold-Levi 
and  de  Rothschild  found  this  agent  use- 
less. The  case  being  attended  with 
marked  myasthenia,  they  adminis- 
tered pituitary  extract,  1^  grains 
(0.1  Gm.)  twice  daily,  which  corre- 
sponded with  7%  grains  (0.5  Gm.)  of 
the  fresh  gland.  Marked  signs  of  im- 
provement appeared  within  a  few 
days.  The  intelligence  developed  to 
a  remarkable  degree,  and  soon  reached 
that  of  a  child  of  a  corresponding  age, 
3  years,  though  before  the  treatment 
it  did  not  exceed  that  of  a  7  or  8 
months'    infant.     Two    similar    cases, 


one  of  which  showed  symptoms  of 
Little's  disease,  were  similarly  bene- 
fited. 

Browning  used  pituitary  only  in 
undersized  or  backward  children  and 
youths  (not  real  dwarfs  or  midgets). 
He  gives  the  following  histories : — 

1.  A  frail,  choreic  girl  of  14  years 
had  made  little  or  no  recent  advance  in 
growth.  On  pituitary,  with  some  ac- 
cessories for  the  chorea,  she  gained  a 
couple  of  pounds  in  weight  and  over  an 
inch  in  height  in  three  and  a  half 
months,  the  chorea  disappearing.  2. 
A  slightly  rachitic  boy  of  2  years,  after 
a  period  of  cessation  of  growth,  in- 
creased from  25  to  over  30  pounds  (i.e., 
over  20  per  cent.)  in  six  months  on  the 
somewhat  irregular  administration  of 
pituitary — besides  recovering  in  all 
ways,  and  keeping  up  his  good  progress 
since,  though  at  a  slower  rate.  Brown- 
ing noted  when  growth  is  once  started 
up  in  this  way  it  usually  keeps  on  sat- 
isfactorily. 3.  A  somewhat  choreic  boy 
of  13  years  and  of  scanty  physique  re- 
ceived pituitary,  besides  at  tim,es  ar- 
senic and  accessories.  Although  his 
growth  was  said  to  have  been  at  a 
standstill  previous  to  this,  he  gained  2 
inches  in  height  and  10  pounds  in 
weight  in  the  next  eight  months.  In 
another  ten  months,  on  somewhat  ir- 
regular continuation  of  the  pituitary, 
he  made  a  further  gain  of  3  inches  in 
height  and  11  pounds  in  weight — when 
the  father  began  to  inquire  anxiously 
for  agents  with  the  opposite  effect. 
This  is  a  record  for  a  year  and  a  half 
of  5  inches  in  height  and  over  20 
pounds  in  weight,  the  patient  having 
been  under  56  inches  and  70  pounds  at 
the  start. 

Intestinal  Paresis. — Bell  and  Hicks 
have  found  pituitary  extract  of  value 
in  paralytic  distention  of  the  intestines. 


ANIMAL   EXTRACTS    (SAJOUS). 


783 


It  never  failed  either  in  postoperative 
or  other  paresis  if  given  intranniscn- 
larly  when  the  intestine  begins  to  dis- 
tend in  15-minim  doses  (0.92  c.c),  re- 
peated in  an  hour  if  required.  The 
effect  is  then  sustained  by  daily  doses 
if  need  be.  The  beneficial  influence  of 
the  injections  was,  as  a  rule,  noticeable 
in  a  few  minutes. 

Pituitary  body  is  a  reliable  agent  for 
the  treatment  of  paralytic  distention 
of  the  bowel.  In  some  respects  the 
preparation  is  far  ahead  of  adrenalin, 
apart  from  its  greater  efficiency  and 
more  prolonged  action  on  the  in- 
voluntary muscle-fibers,  especially  of 
the  heart  and  kidneys.  After  a  short 
initial  increase  in  the  frequency,  the 
extract  slows  the  heart  and  causes 
more  powerful  contraction,  whereas 
adrenalin  causes  acceleration.  While 
adrenalin  causes  a  diminution  in  the 
secretion  of  the  urine,  infundibular 
extract  has  a  marked  diuretic  effect, 
which  is  of  very  great  postoperative 
value.  There  is  also  reason  to  be- 
lieve that  the  extract  may  prove  to 
be  even  more  effective  than  adrenalin 
in  producing  local  anemia.  W.  B. 
Bell  (Brit.  Med.  Jour.,  Dec.  4,  1909). 

Twenty-one  cases  illustrating  the  fact 
that  pituitary  extract  has  a  very,  marked 
effect  upon  the  muscular  coats  of  the 
bowel,  and  that  it  is  able  to  overcome 
the  temporary  paralysis  due  to  ex- 
posure after  abdominal  operations. 
This  is  shown  by  the  early  passage 
of  flatus  and  by  the  absence  of  ab- 
dominal discomfort.  In  only  3  cases 
did  the  bowels  act  without  the  assist- 
ance of  the  enema,  but  in  every  case 
except  2  a  satisfactory  action  of  the 
bowels  was  obtained  after  a  simple 
enema,  and  it  was  necessary  to  give 
any  aperient  by  the  mouth.  All  the 
patients  passed  flatus  freely  within 
a  few  hours  of  the  first  injection,  and 
were  free  from  any  abdominal  pain 
or  distention;  no  patient  complained 
of  flatulence.  The  flatus  was  often 
passed  freely  without  the  introduction 
of    a    flatus    tube.      The    pulse    rate 


remained  much  lower  than  usual, 
and  after  some  of  the  severest  opera- 
tions it  did  not  exceed  80  per  minute. 
Except  in  the  last  2  cases  no  patient 
suffered  from  postoperative  retention 
of  urine,  and  so  catheterization  was 
unnecessary.  The  patients  treated 
with  injections  of  pituitary  extract  after 
abdominal  operations  are  certainly  more 
generally  comfortable  than  those  who 
do  not  receive  them.  L.  A.  Bidwell 
(Clinical  Journal,  Sept.  6,  1911). 

We  have  seen  under  the  caption 
"Obstetrics"  that  pituitary  gland  was 
also  of  value  in  the  intestinal  paresis 
following  pelvic  operations. 

ORCHITIC  OR  TESTICULAR 
ORGANOTHERAPY;  SPERMIN. 

The  mode  of  action  of  these  agents 
has  not  as  yet  been  explained  otherwise 
than  by  the  process  I  have  suggested, 
viz.,  that  it  is  similar  to  that  of  the 
adrenal  products,  owing  to  the  pres- 
ence in  the.se  preparations  of  the  adre- 
nal principle. 

That  the  testicle  influences  power- 
fully the  organism  at  large  is  well 
shown  by  the  fact  that  castration  be- 
fore puberty  modifies  in  many  partic- 
ulars the  development  of  the  individual. 
They  preserve  to  a  certain  extent  the 
characteristics  of  infantilism,  the  skin 
remaining  soft  and  white,  their  muscles 
flabby  and  weak,  and  the  voice  high- 
pitched.  Yet  they  are  usually  tall,  aw- 
ing to  inordinate  growth  of  the  bones. 
They  lack  courage,  initiative,  and  in- 
telligence. It  is  evident,  therefore,  that 
the  testicles  do  not  solely  carry  on  gen- 
ital functions.  Brown-Sequard,  in  fact, 
taught  that  they  carried  on  a  dual  role : 
1,  procreation;  2,  the  production  of 
an  internal  secretion  which  stimulates 
and  sustains  the  energy  of  the  nerve- 
centers  and  cord,  and  capable,  more- 
over, of  endowing  the  individual  with 
physical,  moral,  and  intellectual  char- 


784 


ANIMAL   EXTRACTS    (SAJOUS). 


acteristics  of  sex.  His  own  physical 
and  intellectual  activity  having  been 
greatly  improved  at  the  age  of  72  years, 
by  injections  of  an  extract  prepared 
from  the  testes  of  young  dogs,  he  con- 
cluded that  it  possessed  marked  thera- 
peutic value.  No  one  who,  as  I  did, 
saw  Brown-Sequard  before  and  after 
he  had  submitted  himself  to  this  treat- 
ment could  stretch  his  imagination  suf- 
ficiently to  attribute  the  change  in  his 
appearance  to  autosuggestion.  He  lit- 
erally looked  twenty  years  younger. 
Unfortunately,  the  value  of  testicular 
preparations  was  exaggerated  by  many 
observers  to  such  a  degree  that  their 
use  fell  into  disrepute,  and  the  subject 
has  received  but  little  attention  in  re- 
cent years. 

The  prevailing  opinion  at  the  present 
time  is  that  the  beneficial  effects  db- 
tained  from  testicular  preparations  are 
not  due  necessarily  to  an  internal  secre- 
tion, though  the  existence  of  such  is 
not  denied,  but  to  nucleoalbumins,  sub- 
stances that  are  rich  in  phosphorus,  re- 
sembling greatly  lecithins  and  glycero- 
phosphates. 

Up  to  the  present  time  no  reliable 
evidence  is  forthcoming  to  show  that 
orchitic  injection  has  any  action  other 
than  that  due  to  its  nucleoalbumin,  a 
substance,  of  course,  which  cannot  be 
liberated  into  the  blood-stream.  The 
'  writer  does  not  hint  that  there  is  the 
slightest  doubt  of  the  existence  of  an 
internal  secretion,  but  only  that  its 
nature  is  as  yet  quite  unknown  to  us. 
W.  E.  Dixon  (Brit.  Med.  Jour.,  Sept., 
21,  1907). 

A  personal  analytic  study  of  the 
question  brought  out  a  suggestive 
fact,  viz.,  that  "spermin,"  which  may 
be  obtained  not  only  from  testicles, 
but  from  the  ovaries  of  mammals 
and  fish  roes,  presents  the  character- 
istics of  the   adrenal   secretion,   both 


as  to  composition  and  physiological 
action.  As  I  pointed  out  in  1903  (see 
"Adrenal  Extract,"  supra),  the  adre- 
nal secretion  serves  to  take  up  the 
oxygen  of  the  air  and  carry  it  to 
all  parts  of  the  body  as  the  active 
constituent  of  hemoglobin.  As  such  it 
sustains  oxidation  and  metabolism. 
Now,  Batty  Shaw  ("Organotherapy," 
1st  ed.,  p.  205,  1905)  wTites:  "Spermin 
possesses  the  very  curious  property  of 
being  an  oxygen  carrier,  and,  according 
to  Poehl,  is  responsible  for  those  in- 
ternal oxidations  which  take  place  in 
the  body-tissues.  Again,  I  have  urged 
that  the  adrenal  secretion  carries  on 
its  oxygenizing  function  catalytically  as 
a  ferment.  Pantchenko  (reprint  from 
Trib.  medicale,  1896)  states  that 
"spermin  acts  catalytically,  thus  in- 
creasing the  oxidizing  power  of  the 
blood,  and  simultaneously  activates 
the  intraorganic  oxidation  processes 
where  these  are  weakened."  More- 
over, as  is  the  case  with  the  active 
adrenal  secretion,  spermin  gives  the 
guaiac  and  Florence  hemin  test 
(Mari)  ;  it  is,  as  a  constituent  of  or- 
chitic extract,  unaltered  by  boiling 
(Dixon)  ;  it  increases  the  force  and 
regularity  of  the  heart  much  as 
does  digitalis  (McCarthy)  ;  it  enhances 
the  resistance  to  disease;  it  increases 
the  production  of  urea;  it  acts  directly 
upon  the  cardiovascular  system.  More- 
over, as  shown  by  Poehl^a  fact  which 
indicates  that  it  is  not  specific  to  the 
testis— it  is  a  ubiquitous  constituent  of 
the  whole  organism,  in  the  female  as 
well  as  the  male. 

Abnormalities  in  the  frequency  and 
rhythm  of  the  pulse  are  benefited  by  a 
spermin  when  20  drops  are  given  three 
times  a  day.  Its  power  of  correcting 
irregular  action  of  the  heart  depends 
on  the  fact  that  it  is  an  active  promoter 
of  physiological  tissue   oxidation,   espe- 


ANIMAL   EXTRACTS    (SAJOUS). 


785 


cially  in  the  case  of  ncurin,  xantliin, 
and  other  metabolic  products  which  act 
as  cardiac  poisons,  but  arc  by  oxidation 
converted  into  inactive  compounds.  G. 
von  Hirsch  (Trans.  Congress  of  Intern. 
Med.,  Berlin,  1901). 

Experiments  upon  animals  showing 
that  Poehl's  sperniin  increases  the  vol- 
ume of  the  blood-stream  supplying  the 
heart,  thus  increasing  the  "coefficient  of 
blood  supply  of  the  heart."  Spermin 
acts  more  energetically  in  this  respect 
■  than  the  testicular  emulsion  of  Brown- 
Sequard.  The  action  of  sperniin  de- 
pends upon  its  specific  efifect  on  the 
smooth  muscle-fibers  of  the  cardiac  vas- 
cular system,  and  is  almost  independent 
of  the  muscular  tone  of  the  heart  mus- 
cle and  of  the  heart's  action  itself. 
Sperniin  acts  but  faintly  upon  normal 
hearts,  but  more  markedly  upon  weak- 
ened hearts.  Sperniin  should  be  used, 
therefore,  in  cases  of  diseased  heart 
muscle  and  in  autointoxications  which 
give  rise  to  a  spasmodic  narrowing  of 
the  cardiac  vessels.  Prozhanski  (Rous- 
sky  Vratch,  Nov.  18,  1906). 

Poehl  having  found  in  1895  (Zeit.  f. 
klin.  Med.,  Bd.  xxvi,  H.  1  u.  2)  that 
spermin  was  present  in  all  the  differ- 
ent parts  of  the  organism,  it  becomes 
a  question  whether  its  actual  source 
is  the  testicle,  as  believed  by  him,  or 
whether,  as  I  hold,  it  is  derived  from 
the  adrenals,  the  testicles  being  richly- 
supplied  with  it  only  because  of  the 
importance  of  their  functions,  i.e.,  pro- 
creation. The  relative  importance  of 
both  sets  of  organs  to  life  answers  this 
question.  If,  as  Poehl  says,  "it  is  the 
oxidizing  action  of  spermin  which 
plays  the  principal  role  in  the  phenom- 
ena it  produces,"  the  organs  whose  re- 
moval arrests  oxidation  sufficiently  to 
render  life  impossible  must  be  the 
source  of  the  oxidizing  agent.  As  is 
well  known,  removal  of  the  testicles 
does  not  kill,  while  death  invariably 
follows  extirpation  of  both  adrenals. 
It  is  plain,  therefore,  that  the  testicles 


do  not  produce  the  oxidizing  substance 
shown  by  Poehl  and  others  to  be  the 
active  agent  in  spermin,  and  that  it  is 
the  oxygen-laden  adrenal  secretion 
(adrenoxidase)  it  contains  which  en- 
dows it  with  therapeutic  properties. 

On  the  whole,  the  foregoing  facts 
have  shown  that,  while,  as  held  by 
Dixon,  orchitic  extract  is  a  compound 
of  phosphorus-laden  bodies,  nucleins, 
lecithin,  etc.,  which  acts  much  as  do 
glycerophosphates  and  similar  products 
(though  containing  spermin  in  rel- 
atively small  quantities),  spermin  owes 
its  beneficial  effects  to  the  fact  that  it 
is  rich  in  oxygenized  adrenal  secretion, 
i.e.,  the  product  I  have  termed  adren- 
oxidase. 

THERAPEUTICS.— The  fact  that 
testicular  preparations,  including 
spermin,  have  been  recommended  in 
a  large  number  of  disorders  has  not 
served  to  recommend  them  to  the  im- 
partial observer.  The  use  of  orchitic 
extract  was  extolled  in  various  nerv- 
ous disorders,  especially  tabes,  neu- 
rasthenia, melancholia,  impotence,  and 
paralysis  agitans;  in  several  cutane- 
ous disorders,  eczema  and  psoriasis; 
in  disorders  of  nutrition,  gout,  obesity, 
and  glycosuria ;  but  others  again  have 
failed  to  obtain  any  favorable  results. 
Spermin  has  also  been  recommended 
by  Poehl  and  his  followers  not  only 
in  the  majority  of  the  foregoing  dis- 
orders, but  in  many  others  besides,  in 
acne,  rheumatism,  syphilis, marasmus, 
and  in  various  infections,  such  as 
typhoid  fever,  diphtheria,  and  even 
cholera.  It  has  been  tried  in  Addi- 
son's disease,  but  adrenal  prepara- 
tions are  to  be  preferred. 

In  the  light  of  the  analysis  submit- 
ted above,  however,  there  is  good 
ground  for  the  belief  that  beneficial 
effects  were  obtained  in  all  these  mala- 


1—50 


786 


ANIMAL   EXTRACTS    (SAJOUS). 


dies.  That  the  nucleoalbumins  of 
orchitic  extract,  acting  as  would  glyc- 
erophosphates, could  be  beneficial  in 
the  disorders  enumerated,  no  one  can 
deny.  This  can  hardly  be  said,  how- 
ever, of  the  cutaneous  and  nutritional 
disorders,  unless  the  spermin  the  ex- 
tract contains,  by  enhancing  oxidation 
and  the  destruction  of  toxic  wastes, 
proves  to  be  the  active  agent.  Spermin 
itself — as  adrenoxidase — is  unquestion- 
ably capable  of  doing  this  actively,  and 
in  syphilis  and  marasmus  to  markedly 
enhance  the  functional  activity  of  all 
tissues.  Again,  the  beneficial  role  of 
spermin  in  infections  finds  its  expla- 
nation in  a  fact  I  have  repeatedly 
emphasized,  viz.,  that  the  oxygenized 
adrenal  secretion,  the  active  agent  of 
spermin  from  my  viewpoint,  is  an  ac- 
tive participant  in  all  immunizing 
processes,  local  and  general. 

The  main  point  to  determine,  how- 
ever, is  whether  orchitic  extract  or 
spermin  affords  better  or  as  good  re- 
sults in  any  of  the  disorders  enumer- 
ated than  other  remedies  at  our  dis- 
posal. The  evidence  available  indicates 
that  such  is  not  the  case.  Hence,  the  dis- 
use into  which  the  testicular  products 
have  fallen. 

OVARIAN  ORGANOTHERAPY. 
— The  ovaries  correspond  in  many 
ways  with  the  testes  in  their  influence 
upon  general  development:  their  re- 
moval in  childre:-  causes  them  to  grow 
up  without  feminine  attributes ;  absence 
of  these  organs  prevents  development 
of  the  uterus  and  the  appearance  of 
menstruation;  their  removal  after  pu- 
berty arrests  menstruation  and  leads,  to 
atrophy  of  the  genital  organs.  These 
phenomena  were  attributed  by  Cura- 
tulo,  in  accord  with  Brown-Sequard's 
doctrine,  to  the  loss  of  what  influence 
an   internal   secretion   supplied  by   the 


ovaries  to  the  body  at  large  possessed 
over  its  development.  The  administra- 
tion of  ovarian  substance  in  subjects 
deprived  of  their  ovaries  or  during  the 
menopause  produced  a  marked  amel- 
ioration of  all  distressing  phenomena. 
This  was  found  tO'  be  particularly  the 
case  by  Regis,  of  Bordeaux,  in  the  in- 
sanity and  other  morbid  symptoms 
which  occasionally  follow  operative  re- 
moval of  the  ovaries. 

The  manner  in  which  ovarian  extract 
produces  its  effects  has  remained  ob- 
scure. As  Wilcox  ("Pharmacology  and 
Therapeutics,"  7th  ed.,  p.  824,  1907) 
says :  "But  little  is  known  of  its  phar- 
macological action.  Fresh  ovarian  ex- 
tract is  said,  when  injected  into  the 
circulation  in  rabbits,  to  raise  the  blood- 
pressure,  diminish  the  heart's  action, 
and  slow  the  respiration,  and  when  ad- 
ministered to  the  human  female  also 
to  increase  the  arterial  tension.  In  the 
castrated  animal  it  is  found  to  increase 
oxidation  to  somewhat  above  the  nor- 
mal degree,  but  on  the  normal  animal 
it  has  no  such  effect."  These  are  the 
identical  effects  produced  by  adrenal 
preparations.  From  my  viewpoint,  it 
is,  in  fact,  owing  to  the  presence  of 
this  substance — not  necessarily  an  in- 
ternal secretion — in  the  ovaries  that 
they  must  be  attributed.  There  exists, 
as  shown  by  Schafer,  a  close  homology 
between  the  interstitial  of  the  ovary 
and  the  same  cells  in  the  adrenals ;  both 
sets  of  organs  are  derived  from  the 
Wolffian  body;  ovarian  extract  raises 
the  blood-pressure  and  slows  the  heart, 
as  shown  by  Federoff,  Jacobs,  and  oth- 
ers. Removal  of  the  ovaries,  more- 
over, reduces  the  oxygen  intake  10  per 
cent.,  as  shown  by  Loewy  and  Richter, 
while  ovarian  extract  restores  it;  it 
has  been,  therefore,  regarded  as  an  oxi- 
dizing   ferment.      Neumann    and    Vas 


ANIMAL   EXTRACTS    (SAJOUS). 


787 


noted  that  ovarian  extract  enhanced 
metabolism;  Senator  observed  that 
ovarian  preparations  increased  diuresis 
and  the  excretion  of  urea  and  phos- 
phoric acid.  Its  physiological  effects 
are  those  of  adrenal  preparations,  there- 
fore, in  every  respect. 

Its  effects  on  oxidation  are  so  strik- 
ing, in  fact,  that  they  have  been  clearly 
recognized  by  many  clinicians.  "We 
are  authorized  to  classify  ovarian 
organotherapy  among  the  oxidizing 
agents,"  write  Dalche  and  Lepinois. 
"This  conclusion,  it  must  be  admitted, 
is  that  reached  by  several  authors.  Cur- 
atello  and  Tarulli  believe  that  the  in- 
ternal secretion  of  the  ovaries  favors 
the  oxidation  of  phosphorized  organic 
substances,  hydrocarbons,  and  fats. 
According  to  Gomes,  it  enhances  oxi- 
dation and  hydrolysis  and  favors  the 
elimination  of  phosphates.  .  .  . 
Albert  Robin  and  Maurice  Binet  have 
shown  that  there  is  during  menstrua- 
tion an  increase  of  the  respiratory  ex- 
changes. Keller,  studying  the  general 
exchanges,  found  that  there  was  in- 
creased nitrogen  oxidation.  We  have 
ourselves  found  that  menstruation,  in 
itself,  enhances  vital  functions  and 
particularly  the  great  function  of  gen- 
eral oxidation." 

Ovarian  extract  causes  an  excretion 
of  the  phosphates,  which  is  less  marked 
in  women  whose  ovaries  have  been  re- 
moved. In  general,  castration  appears 
to  diminish  the  salts  in  the  body. 
Mathes  (Monats.  f.  Geb.  u.  Gyn.,  Bd. 
xviii,  H.  2,  1904). 

The  ovary  appears  to  preside  in  some 
waj'-  over  the  metabolism  of  inorganic 
matter,  and,  hence,  aids  in  maintaining 
the  composition  of  the  blood.  Thus 
when  young  bitches  are  castrated  there 
is  an  initial  reduction  of  the  number  of 
er3rthrocytes  and  amount  of  hemoglobin. 
Ofifergeld  (Deut.  med.  Woch.,  June  22, 
29,  1911). 


PREPARATIONS  AND  DOSES. 

— The  preparation  in  general  use  is  the 
desiccated  gland,  available  in  the  form 
of  2-grain  tablets,  which  may  be  given 
in  doses  of  2  to  4  grains  (0.132  to  0.26 
Gm.)  twice  daily.  The  fresh  organ 
may  be  employed  in  10-  to  15-  grain 
(0.6  to  1.0  Gm.)  doses  where  the  phar- 
maceutical product  is  not  available.  As 
the  patient  becomes  readily  habituated 
to  the  remedy,  it  is  best  to  begin  with 
small  doses  and  to  increase  them  grad- 
ually. It  owes  its  action  to  the  cor- 
pus luteum  it  contains. 

THERAPEUTICS.— As  in  the  case 
of  testicular  preparations  and  spermin, 
ovarian  extractives  have  been  tried  in 
a  multitude  of  disorders  with  more  or 
less  benefit  or  without  any  whatever. 

Natural  and  Artificial  Menopause. 
— In  disorders  occurring  in  the  course 
of  the  physiological  menopause,  or 
when  the  latter  is  produced  by  bilateral 
oophorectomy,  ovarian  preparations 
have  proven  of  considerable  value  in  a 
large  proportion  of  cases  since  Brown- 
Sequard  first  introduced  their  use.  Ex- 
perience has  shown,  however,  that  the 
improvement  lasts  only  as  long  as  the 
agent  is  administered,  and  that,  fur- 
thermore, certain  phenomena :  the 
palpitation,  trembling,  and  "nervous- 
ness," disappear  earlier  than  the  oth- 
ers, i.e.,  the  asthenia,  flushes,  irritabil- 
ity, and  psychoses,  though'  effects  in 
all  symptoms,  including  the  cutaneous 
disorders — especially  acne  rosacea  and 
eczema — are  promptly  realized,  some- 
times as  early  as  the  fourth  day. 

These  effects  are  normally  explained 
by  the  influence  of  the  remedy  on  gen- 
eral oxidation  and  the  improvement  of 
the  antitoxic  functions  of  the  blood,  the 
imperfect  hydrolysis  of  tissue  wastes 
being  the  underlying  cause  of  the  phe- 
nomena other  than  the  general^sthenia. 


788 


ANIMAL   EXTRACTS    (SAJOUS). 


The  best  results  are  obtained  in 
young  women  who  have  grown  obese 
after  removal  of  the  ovaries,  or  in 
whom  obesity  is  due  to  ovarian  in- 
sufficiency. In  physiological  meno- 
pause they  are  less  marked,  as  a  rule, 
and  sometimes  fail  altogether  to  ap- 
pear. In  such  instances,  good  results 
may  sometimes  be  obtained  by  giving 
simultaneously  1  grain  (0.066  Gm.) 
desiccated  thyroid,  or  by  depending 
upon  the  latter  remedy  alone.  In  the 
amenorrhea  of  congenital  ovarian  in- 
sufficiency, desiccated  ovary  has  caused 
the  appearance  of  menstruation. 

W.  E.  Dixon,  of  Cambridge  Univer- 
sity, recalls  that  the  presence  of  ovarian 
tissue  in  the  body,  however  small  in 
amount,  is  sufficient  to  prevent  the  dis- 
tressing symptoms  which  frequently 
follow  complete  extirpation ;  even  trans- 
planted ovaries  are  sometimes  able  to 
prevent  the  menopause  attending  re- 
moval of  the  ovaries.  Hence,  the  ben- 
eficial effects  of  ovarian  preparations. 

Improvement  has  also  been  ob- 
tained by  some  observers  in  acne, 
prurigo,  and  eczema.  They  have  been 
found  to  cause  an  increase  of  the  red 
corpuscles  in  chlorosis  and  to  afl'ord 
benefit  in  gout,  epilepsy,  exophthal- 
mic goiter  and  obesity,  and  also  in 
dysmenorrhea. 

Of  late,  however,  the  general  atten- 
tion has  been  centered  upon  the  thera- 
peutic use  of  the  essential  structure  of 
the  ovary,  the  corpus  luteum. 

CORPUS  LUTEUM  ORGANO- 
THERAPY. 

The  consensus  of  opinion  at  the  pres- 
ent time  is  that  the  internal  secretion 
of  the  ovary  is  produced  by  the  corpus 
luteum.  The  function  of  the  corpora 
lutea  in  the  early  stages  of  their  life 
is  to  initiate  growth  processes  in  the 
uterine  cavity  by  means  of  this  internal 


secretion  and  subsequently  to  preside 
over  the  nidation  and  development  of 
the  ovum,  and  the  cyclic  engorgement 
preceding  menstruation.  The  recent  la- 
bors of  Fraenkel  confirming  his  previ- 
ous investigations  have  strongly  sus- 
tained the  internal  secretion  theory 
and  its  controlling  influence  over  the 
above  functions.  He  found,  moreover, 
that  the  therapeutic  value  of  corpus  lu- 
teum was  limited  to  cases  presenting 
symptoms  of  vasomotor  origin  due  to 
absent  or  deficient  ovarian  activity. 

This  coincides  with  the  earlier  con- 
clusion of  J.  G.  Clarke  that  the  office 
of  the  corpus  luteum  was,  among  oth- 
ers, that  of  "a  preserver  of  the  ovarian 
circulation" — a  fact  which  explains  in 
turn  the  presence  of  adrenal-like  tissue, 
whose  secretion,  as  is  well  known,  is 
eminently  capable  of  sustaining  vascu- 
lar tone.  Indeed,  as  is  generally  be- 
lieved, it  is  the  corpus  luteum  which 
produces  the  ovarian  internal  secre- 
tion; it  should,  in  accord  with  what  I 
have  stated  concerning  the  mode  of 
action  of  the  ovaries,  also  produce  ef- 
fects similar  to  those  of  adrenal  prep- 
arations. We  need  but  recall  that  in 
the  adrenal  hypernephroma  of  children 
one  of  the  essential  phenomena  wit- 
nessed is  the  extraordinary  develop- 
ment of  the  genital  organs,  those  of  a 
child  of  5  years,  for  instance,  being 
practically  those  of  an  adult.  Bouin, 
Ancel,  and '  Villemin  found  that  the 
primary  efifect  of  toxic  doses  of  lutean 
extract  was  a  violent  elevation  of  the 
blood-pressure,  sufficient  to  produce  ef- 
fusion into  all  serous  cavities.  The 
physiological  eiTects  of  therapeutic 
doses  have  not  been  sufficiently  studied 
to  show  positively,  as  was  the  case  with 
the  ovaries,  that  they  are  all  those  of 
adrenal  preparations,  though  what  there 
is  known  points  in  that  direction.    One 


ANIMAL   EXTRACTS    (SAJOUS). 


789 


fact  is  certain,  however,  viz.,  the  func- 
tions of  the  organ  should  not  be  as- 
cribed to  its  internal  secretion;  its 
mission  is  probably  limited  to  that  of 
sustaining  the  ovarian  circulation,  as 
pointed  out  by  J.  G.  Clarke. 

On  the  whole,  from  my  viewpoint, 
the  physiological  action  of  corpus  hi- 
teum,  in  organotherapy,  is  that  of 
ovarian  substance  (q-"'-'-),  which,  in 
turn,  as  we  have  seen,  is  mainly  that  of 
adrenal  substance  in  organic  combi- 
nation. 

PREPARATIONS  AND 
DOSES. — The  preparations  available 
include  desiccated  corpus  luteum 
(gJa)idulcc  Intel  desiccatcv),  which  may 
be  given  in  3-  to  5-  grain  (0.2  to  0.3 
Gm.)  doses  three  times  daily.  It  is 
usually  administered  before  meals,  but 
if,  as  is  sometimes  the  case,  it  causes 
gastric  disturbances  it  may  be  admin- 
istered during,  that  is  to  say,  in  the 
course  of,  the  meal.  The  term  "lutein" 
is  sometimes  applied  to  the  same  prod- 
uct, but  it  is  misleading,  and  its  use 
should  be  discouraged. 

THERAPEUTICS.  — The  indica- 
tions for  desiccated  luteum  are  similar 
to  those  for  ovarian  preparationr. 

Natural  and  Postoperative  Meno- 
pause and  Disorders  of  Pregnancy, — 
It  must  be  said  that  the  evidence  as  to 
the  therapeutic  value  of  desiccated 
luteum  is,  to  say  the  least,  conflicting. 
Alorley,  wdio  supplied  desiccated  lu- 
teum to  ten  physicians,  and  obtained 
reports  of  its  use  in  18  cases,  14  of 
which  suffered  from  postoperative 
menopause,  and  4  from  natural  meno- 
pause, states  that  5  were  cured,  12  im- 
proved, and  that  but  1  failed  to  be 
relieved. 

C.  A.  Hill  also  reported  results  ob- 
tained with  extract  of  corpora  lutea  in 
12  patients,  ranging  in  age  from  25  to 


38  years,  who  showed  the  most  severe 
type  of  nervous  symptoms  after  re- 
moval of  both  ovaries.  The  "nervous- 
ness" was  completely  relieved  by  the 
treatment  in  each  case.  In  only  2  cases, 
however,  was  there  complete  relief  from 
flashes  of  heat.  In  another  case,  suffer- 
ing from  insomnia,  which  had  contin- 
ued ever  since  the  operation  over  a 
year  before,  and  was  uninfluenced  by 
hypnotics,  complete  relief  was  attained 
after  the  use  of  50  5-grain  (0.33  Gm.) 
capsules.  One  case  reported  an  in- 
crease in  sexual  desire,  while  in  the  re- 
mainder no  noticeable  change  was  ex- 
perienced. No  complete  cures  were 
obtained.  Several  cases  had  interrupted 
treatment  only,  and  others,  who  ceased 
treatment,  were  compelled  to  resume 
owing  to  return  of  symptoms.  The 
preparation  in  each  case  was  given  in 
5-grain  (0.33  Gm.)  capsules  three 
times  daily,  one-half  to  one  hour  before 
meals. 

On  the  other  hand,  EUice  McDon- 
ald publishes  a  report  of  20  personal 
cases  in  which  he  had  used  a  similar 
preparation.  "The  results  of  this  study, 
small  though  they  be,  extending  over 
five  years,"  writes  this  observer  in  his 
conclusions,  "seem  to  indicate  that  the 
control  of  surgical  menopause  need 
not  be  sought  in  the  corpora  lutea. 
Its  value  is  in  cases  in  which  the 
uterus  and  ovaries  or  uterus  alone  are 
retained.  Particularly  is  it  valuable 
in  the  treatment  of  scanty  menstru- 
ation and  the  premature  menopause. 
I  have  treated  a  number  of  cases  at 
the  outdoor  dispensary  of  the  Ken- 
sington Hospital  for  Women,  with 
extract  of  the  whole  ovary,  and  never 
saw  any  definite  results  therefrom. 
But  the  lutein  extract,  being  the  es- 
sential part  of  the  ovary,  does  seem 
to  help  in  some  desfree  and  should  be 


790 


ANIMAL   EXTRACTS    (SAJOUS). 


accompanied,  in  suitable  cases,  by  dil- 
atation of  the  uterus,  with  the  use  of 
the  stem  pessary  following  operation, 
as  advised  by  Manson.  At  least,  ad- 
ministration of  lutein  is  indicated 
after  operations  on  pregnant  women 
in  whom  miscarriage  is  feared.  This 
is  particularly  true  in  the  early  weeks 
of  pregnancy  during  the  imbedding  of 
the  ovum,  as  it  has  been  shown  ex- 
perimentally that  the  corpus  luteum 
has  a  definite  effect  under  such  cir- 
cumstances." There  is  also  some 
ground  for  the  belief  that  it  will  prove 
of  some  value  in  osteomalacia  and  in 
agalactia,  i.e.,  as  a  galactogogue. 

The  consensus  of  opinion  seems  to  be 
that  the  internal  secretion  of  the  ovary- 
is  produced  by  the  yellow  body.  The 
extract  may  be  given  in  S-grain  doses, 
three  times  a  day,  from  one-half  to  one 
hour  before  meals.  The  writer's  re- 
sults in  18  cases  were  as  follows :  5 
were  cured,  12  were  improved,  and  1 
obtained  no  relief.  Included  in  these 
12  are  grouped  those  who  are  still 
taking  the  extract.  A  permanent  cure 
may  result  in  a  few  of  those  under 
treatment.  Of  the  18  patients,  14  suf- 
fered from  disturbances  of  operation  or 
artificial,  and  4  from  those  of  natural 
or  physiologic  menopause.  Morley 
(Jour.  Mich.  State  Med.  Soc,  Nov., 
1909). 

The  extract  of  human  corpus  luteum 
possesses  a  distinct  therapeutic  action 
in  osteomalacia,  disturbances  of  the 
natural  and  artificial  menopause,  and 
in  hypofunction  due  to  infantile 
uterus.  In  amenorrhea  and  in  dys- 
menorrhea the  treatment  must  at  first 
be  given  each  month.  Maits  (Univ. 
of  Penna.  Med.  Bull.,  July-Aug., 
1910). 

In  experiments  upon  the  goat  with 
the  glands  containing  internal  secre- 
tions, the  writers  found  that  the  thymus 
and  corpus  luteum  increase  the  quan- 
tity of  milk  fourfold  in  five  minutes. 
The  ovary  minus  corpus  luteum  has  no 
effect.      Infundibulin    is    still    the    most 


powerful  galactogogue,  increasing  the 
secretion  of  milk  one  hundredfold. 
The  amount  of  butter  fat  is  about  the 
same  in  the  augmented  secretion  by 
thymus,  corpus  luteum,  and  infundib- 
itlin,  though  occasionally  it  is  increased. 
Ott  and  Scott  (Mo.  Cyclo.  and  Med. 
Bull.,  Feb.,  1911). 

It  is  obvious  that  the  clinical  experi- 
ence at  our  disposal  is  still  too  limited 
to  warrant  any  decision  as  to  the  actual 
value  of  corpus  luteum,  though  it  must 
be  said  that  many  desultory  cases  have 
been  published  in  which  its  rise  was  ex- 
tolled. McDonald  rightly  lays  stress  on 
the  facts  that  "the  manifestations  of 
the  surgical  menopause  are  too  varied 
and  extreme  to  allow  explanation  by 
the  mere  absence  of  the  internal  secre- 
tion of  the  ovary.  The  internal  secre- 
tion of  the  ovary  is  but  a  factor  in  the 
process  of  the  menstrual  life." 

I  would  go  one  step  farther  and  ex- 
press a  doubt  that  we  are  dealing  at  all 
with  an  "internal  secretion,"  a  designa- 
tion applied  to  almost  any  organic  juice 
nowadays,  and  reiterate  what  I  say 
elsewhere,  viz.,  that  true  internal  secre- 
tions are  fewer  than  is  generally  be- 
lieved. 

KIDNEY    ORGANOTHERAPY. 

Brown-Sequard,  having  removed  the 
kidneys  and  caused  uremia,  found  that 
the  injection  of  a  glycerin  extract  of 
kidney  prolonged  the  life  of  the  animals 
as  compared  to  those  in  which  the  same 
operation  was  not  followed  by  the  use 
of  the  kidney  extract.  This  experiment, 
which  has  been  repeated  by  others, 
forms  the  basis  of  the  belief  that  the 
kidney  produces  an  internal  secretion. 
That  such  a  conclusion  may  not  be 
warranted  is  suggested  by  the  fact  that 
the  kidneys,  along  with  some  of  the 
organs  so  far  reviewed,  are  also  rich 
in  adrenal  tissue — the  so-called  "adre- 
nal rests"  from  hypernephroma  some- 


ANIMAL   EXTRACTS    (SAJOUS). 


791 


times  develops — and  that  as  such  they 
are  capable,  as  an  active  factor  in  the 
immunizing  functions  of  the  body,  of 
counteracting  temporarily  the  toxemia 
or  "uremia"  brought  on  by  removal  of 
the  kidneys.  Indeed,  the  relief  afforded 
is  but  ephemeral,  death  being  post- 
poned but  one  or  two  days  in  rabbits, 
in  which  Bitzou  repeated  Brown-Se- 
quard's  experiments.  Dromain  and  de 
Pradel  Bra  had  also  noticed  that  injec- 
tions of  kidney  extract  lessened  the  fits 
of  epilepsy,  another  toxemia.  Dubois 
and  Renaut  have  already,  in  fact,  at- 
tributed antitoxic  power  to  kidney  ex- 
tracts. 

That  we  are  again  dealing  mainly 
with  a  manifestation  of  the  adrenal 
principle  is  further  suggested  by  its 
powerful  blood-pressure-raising  prop- 
erty. Tigerstedt  and  Bergman  found 
that  rennin  possessed  this  power;  Bin- 
gel  and  Strauss  recently  confirmed  their 
observation,  and  found  that  its  action 
corresponded  with  that  of  adrenal  and 
pituitary  extracts,  those  of  other  or- 
gans causing  depressor  effects.  The 
use  of  pressure  produced  by  kidney  ex- 
tract was  high,  i.e.,  from  40  to  60  mm. 
Hg ,  and  lasted  from  fifteen  to  thirty 
minutes.  The  authors  concluded,  more- 
over, that  "the  action  of  rennin,  like 
that  of  adrenalin,  is  exerted  in  the  mus- 
cles of  the  peripheral  vessels."  Its  gen- 
eral action,  however,  is  more  like  that 
of  pituitary  body  extract,  the  adrenal 
principle  being  doubtless  combined  or- 
ganically, as  in  the  pituitary,  with 
bodies  which  prolong  and  perhaps  con- 
trol advantageously  the  action  of  the 
former.  Like  adrenal  preparations  kid- 
ney extract  also  produces  myosis. 

Even  the  oxidizing  power  I  have  at- 
tributed to  the  adrenal  secretion  seems 
to  be  reproduced;  Batty  Shaw,  who 
also  finds  "very  little  justification  for 


the  existence  of  an  internal  secretion" 
in  the  kidney,  remarks  that  ''possibly 
nephrin  and  other  renal  preparations 
provide  a  means  of  stimulating  oxida- 
tion in  general,  the  kidney  merely  shar- 
ing in  this  oxidation" — a  very  accurate 
estimate  from  my  viewpoint.  Shaw 
adds,  moreover,  that  "similar  good  re- 
sults have  been  reported  as  a  result  of 
treatment  by  means  of  spermin  and 
testicular  extract,"  both  of  which,  as  I 
have  shown,  also  owe,  in  all  probabil- 
ity, their  therapeutic  effects  to  the  adre- 
nal principle  they  contain. 

THERAPEUTICS  AND  DOSE. 
— The  therapeutic  application  of  kid- 
ney preparations  has  received  consid- 
erable attention,  and  favorable  results 
have  been  reported  in  about  one-half 
of  the  cases  of  chronic  nephritis,  or 
Bright's  disease,  in  which  it  was  tried. 
The  mode  of  action,  in  the  light  of  the 
facts  submitted  above,  is  mainly  an  in- 
crease of  the  antitoxic  power  of  the 
blood  and  diminution,  therefore,  of  the 
irritation  of  renal  apparatus.  Page  and 
Dardelin,  for  example,  report  marked 
amelioration  in  18  cases,  using  a  mac- 
eration prepared  as  follows :  A  very 
fresh  kidney  from  a  pig  is  cut  into 
minute  pieces,  washed  with  fresh  water 
to  remove  the  ex-cess  of  urine,  then 
hashed  and  pounded  into  pulp.  This 
pulp  is  put  into  300  Gm.  (9  ounces  and 
5  drams)  of  fresh  water  to  which  the 
physiological  proportion  of  salt,  7.50  to 
1000,  has  been  added.  It  is  then  al- 
lowed to  macerate  for  three  hours, 
stirred  occasionally,  and  kept  in  a  cool 
place  to  avoid  fermentation.  The  red 
water  of  the  maceration  is  divided  into 
three  parts,  to  be  drunk  by  the  patient 
during  the  day.  It  is  more  conveniently 
given,  however,  in  tablet  form,  as 
"nephritin,"  prepared  in  this  country  by 
Reed    and    Carnrick.     Only   the   active 


792 


ANIMAL   EXTRACTS    (SAJOUS). 


substance  of  the  kidney  is  used  in  this 
preparation,  the  dose  being  from  10  to 
15  S-grain  (0.33  Gm.)  tablets  daily  in 
divided  doses,  given  between  meals. 

Kidney  preparations  have  also  been 
used  with  more  or  less  advantage  in 
puerperal  intoxications  and  epilepsy, 
but  their  field  is  essentially  the  va- 
rious forms  of  nephritis,  and  particu- 
larly for  the  prevention  of  uremia. 
They  also  tend  to  increase  diuresis  and 
reduce  the  albumin.  As  stated  above, 
however,  favorable  effects  are  to  be  ex- 
pected in  about  one-half  of  the  cases. 

THYMUS    ORGANOTHERAPY. 

In  1907,  I  submitted  evidence  which 
had  led  me  to  suggest  that  the  function 
of  the  thymus  was  to  supply  an  excess 
of  phosphorus  in  organic  combination 
during  the  growth  of  the  body,  i.e., 
particularly  while  the  development  of 
the  osseous  and  nervous  systems  de- 
manded such  a  reserve.  This  was  sus- 
tained hy  the  recognized  fact  that 
certain  diseases  of  children  and  ado- 
lescents, especially  marasmus,  rachitis, 
and  trophic  disorders  of  the  brain  and 
nervous  system,  were  due,  in  part,  to 
the  functions  of  the  thymus.  While  it 
cannot  be  affirmed  that  this  theory  ac- 
tually represents  the  function  of  the 
organ — the  thymus  having  been  the 
graveyard  of  many  hypotheses — all 
that  can  be  said  for  it  is  that  it  seems 
to  account  for  the  clinical  results  ob- 
tained under  its  use  better  than  any 
hypothesis  so  far  advanced,  besides 
corresponding  with  the  laboratory  find- 
ings of  its  effects. 

THERAPEUTICS.  — Diseases  of 
the  Thyroid. — In  simple  goiter  it  was 
first  tried  by  Mikulicz,  who  obtained 
sufficiently  favorable  results  in  5  out  of 
1 1  cases  to  render  operation  unneces- 
sary, at  least  for  the  time  being.  Rein- 
bach  considers  it  probably  superior  to 


thyroid  because  the  unpleasant  effects 
of  the  latter  are  avoided ;  for  the  same 
reason  it  is  especially  suitable  when 
organotherapy  has  to  be  used  contin- 
uously. This  view  is  based  on  the  em- 
ployment of  thymus  in  a  large  number 
of  cases  in  the  Breslau  clinic.  Mikulicz 
gave  from  2^  to  4  drams  (10  to  16 
Gm.)  of  the  raw  sheep  thymus  on 
bread  three  times  a  week,  increasing 
the  dose  slightly  if  required. 

In  exophthalmic  goiter  it  had  proven 
efficacious  in  the  hands  of  Owen  in 
advanced  cases,  and  also  in  those  of 
Mande  when  other  remedies  had  been 
used  fruitlessly.  The  latter  gave  45 
grains  (3  Gm.)  daily  to  a  severe 
case,  which  greatly  improved,  relaps- 
ing whenever  the  treatment  was  inter- 
rupted. S.  Solis-Cohen  also  advocates 
its  use  in  this  disease,  having  found 
that  it  exerted  its  beneficial  influence 
mainly  upon  the  nervous  symptoms  of 
the  disease  without  affecting  the  ex- 
ophthalmus.  Huston  White  found  that 
the  nervous  symptoms  were  alone  im- 
proved. 

These  observations  coincide  with  my 
own  view  of  the  manner  in  which  thy- 
mus gland  produces  its  beneficial  ef- 
fects. The  excess  of  thyroiodase  pro- 
duced in  exophthalmic  goiter  causes, 
we  have  seen,  too  rapid  oxidation  of 
the  phosphorus  in  organic  combination 
in  the  tissues,  particularly  in  those  of 
the  nervous  system,  which  are  ex- 
tremely rich  in  phosphorus.  Thymus, 
supplying  phosphorus  in  organic  com- 
bination, replaces  that  lost  by  the  nerv- 
ous system,  thus  procuring  marked 
benefit  in  this  one  direction.  As  5 
grains  (0.33  Gm.)  of  the  dried  thymus 
are  equivalent  to  30  grains  (2  Gm.)  of 
the  fresh  gland,  this  dose  can  readily 
be  given  three  times  daily. 

Rachitis,  or  Rickets. — The  same  ex- 


ANIMAL   EXTRACTS    (SAJOUS). 


793 


planation,  i.e.,  the  purveying  of  phos- 
phorus in  organic  combination — to  the 
osseous  system,  in  the  present  connec- 
tion— accounts  for  the  un(lou1)ted  ben- 
efit thymus  has  procured  in  this  dis- 
order. Alendel,  having  used  thymus 
gland  in  1%  to  3  drams  (6  to  12  Gm.) 
daily  in  over  100  cases,  obtained  marked 
benefit  in  a  large  proportion,  but  espe- 
cially in  the  nervous  symptoms,  includ- 
ing spasm  of  the  glottis.  It  had  previ- 
ously been  tried  by  Stoppato,  but  with- 
out marked  benefit.  In  Mendel's  cases 
both  fresh  and  commercial  tablets  w^ere 
tried,  the  cases  being  subdivided  as  fol- 
lows: 1,  those  which  showed  prodro- 
mal symptoms  only ;  2,  those  in  which 
deformity  of  the  osseous  system  was 
the  chief  feature ;  3,  those  marked  by 
spasm  of  the  glottis,  and,  4,  those  in 
which  splenic  enlargement  was  the  most 
important  sign.  Marked  improvement 
was  noted  in  all  after  from  three  to 
four  weeks,  and  dentition  and  the  clos- 
ure of  the  fontanelle  proceeded  satis- 
factorily. No  untoward  symptoms  were 
noted — a  marked  advantage  over  thy- 
roid preparations.  In  a  case  of  stunted 
growth,  obviously  of  osseous  origin, 
in  a  boy  of  14  years,  R.  Webb  Wilcox 
obtained  9^4  inches  growth  in  three 
years  by  the  persistent  use  of  2  grains 
(0.13  Gm.)  thymus  night  and  morning. 
The  view  that  these  effects  are  due 
to  the  addition  of  phosphorus  in  organic 
combination  to  the  body  is  further  sus- 
tained by  the  results  of  experimental" 
observation  by  Hart  and  Nordmann, 
that  the  thymus  had  a  definite  relation 
to  assimilation,  and  that  it  took  an 
active  part  in  the  resistance  of  the  or- 
ganism to  infection.  As  my  own  inves- 
tigations have  shown  (see  the  second 
volume  of  "Internal  Secretions,"  page 
878),  nucleoproteid,  in  so  far  as  its 
phosphorus   in  organic   combination   is 


concerned,  is  an  active  participant  in  the 
immunizing  process. 

Great  relief,  particularly  from  the 
pain  of  cancers,  can  be  attained  by  the 
use  of  thymus  extract.  This  line  of 
treatment  was  originally  worked  out 
by  Gwyer,  who  showed  that  in  cases 
where  the  treatment  was  tried  there 
was  marked  decrease,  or  even  elimi- 
nation, of  pain.  The  glands  used 
were  received  fresh.  The  fat  was 
removed,  and  the  glandular  substance 
cut  up  and  dried  at  a  low  tempera- 
ture by  a  forced  draught  of  air, 
then  £,round  and  sifted  to  a  uniform 
powder.  Of  this  a  dose  of  from  1  to 
4  drams  was  given  three  or  four  times 
a  day.  Gwyer  also  prepared  a  watery 
extract  from  the  dried  gland  by  adding 
the  dried  powder  and  some  thymol  to 
a  solution  of  normal  saline,  straining 
and  filtering  as  rapidly  as  possible, 
filtering  twice,  and  then  adding  50 
per  cent,  acetic  acid.  The  precipitate 
so  obtained  was  separated  by  filtration 
and  redissolved,  using  about  lj4  ounces 
of  the  solution.  Each  dram  of  the 
solution  represents  the  products  from 
half  a  dram  of  the  dried  gland.  The 
process  for  the  production  of  an  ounce 
of  the  extract  takes  about  six  hours. 
This  fluidextract  is  administered  either 
by  mouth  or  hypoderniically  up  to  1 
dram.  Takaki  (Hospital,  Jan.  21, 
1911). 

BONE-MARROW  ORGANO- 
THERAPY. 

The  bone-marrow  being  the  source 
of  red  corpuscles,  its  preparations 
have  been  tried  in  pernicious  anemia, 
the  secondary  anemias,  chlorosis,  ma- 
laria, leucocythemia,  leukemia,  Hodg- 
kin's  disease,  rickets,  and  other  dis- 
orders of-  the  osseous  system.  In  all  of 
these  affections  bone-marrow  gave  good 
results  in  some  cases,  while  an  equal 
number  were  in  no  way  influenced. 
This  obviously  suggests  that  its  indica- 
tions coincide  with  certain  phases  or 
stages  of  the  disease  which  have  not 


794 


ANIMAL   EXTRACTS    (SAJOUS). 


as  yet  been  determined.     The  average 
dose  is  5  grains,  after  meals. 

BRAIN  AND  NERVE  SUB- 
STANCE  ORGANOTHERAPY. 

The  belief,  based  on  pure  assumption, 
that  brain  and  nerve  substance  possess 
or  produce  an  internal  secretion  has 
never  been  sustained  scientifically. 

The  clinical  results,  though  quite 
discordant,  particularly  in  the  neu- 
roses and  psychoses  in  which  these 
preparations  have  been  tried,  have 
shown  a  tendency  to  harmonize  since 
the  introduction  by  Sciallero  of  an 
oily  extract.  Page,  who  has  obtained 
unusually  good  results  in  neurasthe- 
nia by  means  of  injections  of  this  ex- 
tract, ascribes  them  to  its  antitoxic 
and  antispasmodic  eiTects.  Wasser- 
mann  and  Takaki  had  previously  shown 
that  tetanus  toxin  was  neutralized  by 
contact  with  brain  substance,  and 
that  when  a  fatal  dose  of  tetanus  toxin 
was  injected  with  brain  substance  the 
fatal  effects  were  prevented.  The 
same  observations  were  made  in  the 
case  of  hydrophobia  by  Babes ;  in 
strychnine  and  morphine  poisoning 
by  Widal  and  Nobecourt;  in  tetanus 
by  Krokiewicz;  in  epilepsy  by  Lion, 
and  also  Kaplan,  using  Poehl's  opo- 
cerebrin — in  accord  with  Dana's  expe- 
rience several  years  earlier.  Sciallero, 
who  obtained  encouraging  results  in 
neurasthenia,  hysteria,  chorea,  tic, 
and  epilepsy,  used  his  oily  extract 
"cephalopin"  in  doses  varying  from  1 
to  5  c.c.  (16  to  81  minims).  No  un- 
toward efifects  were  obtained. 

Although  it  is  very  improbable  that 
brain  extracts  injected  into  the  tissues 
act  as  they  do  in  the  test-tube,  it  seems 
established  that  they  act  much  as  do  the 
lecithins  on  the  market,  i.e.,  by  furnish- 
ing phosphorus  to  the  organism  in  an 
assimilable  form,  or  as  nucleoproteids 


in  enhancing  the  immunizing  process. 
Be  this  as  it  may,  these  substances  seem 
to  have  produced  effects  which  suggest 
that  they  should,  not  as  yet,  be  set 
aside. 

MAMMARY  GLAND  ORGANO- 
THERAPY. 

It  is  held  by  some  that  the  mammary 
gland  produces  an  internal  secretion; 
but  the  evidence  is  so  scant  that  it  can 
hardly  be  taken  into  account. 

There  are  various  indications  that  the 
mammary  gland  may  be  the  source  of 
an  internal  secretion.  Ovarian  insuffi- 
ciency, for  example,  is  often  accom- 
panied by  congestive  or  painful  phenom- 
ena in  the  breasts.  Again,  the  mam- 
mary gland  can  compensate  for  another 
organ.  Thus,  Djemil  Pacha,  after  re- 
moving two  hypertrophied  breasts  from 
a  man,  w^itnessed  the  development  of 
marked  cachexia  strumipriva  in  his  pa- 
tient. Apert,  Leopold-Levi,  and  de 
Rothschild  have  also  observed  the  con- 
comitant presence  of  gynecomastia  with 
hypothyroidia.  The  purpose  of  the 
mammary  secretion  would  seem  to  be, 
however,  that  of  acting  as  antagonist 
to  that  of  the  ovaries.  Luncz  (Revue 
medico-chirurgicale,  Aug.  1,   1911). 

Although  mammary  gland,  introduced 
by  Bell,  of  Glasgow,  and  in  the  United 
States  by  the  late  John  H.  Shober,  has 
been  used  considerably,  and  has  shown 
a  marked  stimulating  action  upon  the 
uterus,  the  manner  in  which  it  produces 
this  effect  has  remained  obscure.  An 
extract  lowers  somewhat,  and  but  tem- 
porarily, the  blood-pressure  and  the 
pulse.  According  to  Shober,  it  dimin- 
ishes the  blood  supplied  to  the  uterus 
and  thus  controls  hemorrhage,  its  action 
resembling  that  of  ergot,  though  free 
of  the  unpleasant  effects  of  the  latter 
drug. 

Mammary  gland  is  prepared  in  the 
form  of  a  tablet  made  of  the  desiccated 
gland  of  the  sheep,  each  tablet  repre- 


ANIMAL   EXTRACTS    (SAJOUS). 


795 


senting  20  grains  (l--^-  Gm.)  of  the 
fresh  gland.  The  dose  is  from  3  to  6 
tablets  daily. 

The   therapeutic   applicalimi   is   re- 
stricted to  the  genital  api)aratus.     In 
cases  of  uterine  fibroids  characterized 
by  excessive  menorrhagia  and  metror- 
rhagia   the    bleeding    was    found    by 
Shober  to  be  controlled  in  a  few  weeks 
and   the   periods  become   regular,  nor- 
mal, and  free  from  pain.     There  is  im- 
provement in  the  patient's  health  and 
weight,  and  the  tumors  themselves  di- 
minish  in   size   up   to   a   certain  point. 
In  43  cases  treated  by  Fedoroff,  com- 
plete   cure   occurred   in   one-third,    i.e., 
33  per  cent.;  a  reduction  of  volume  in 
43  per  cent.,  and  no  result  whatever  in 
14  per  cent.     The  hemorrhages  disap- 
peared completely  in  80.3  per  cent,  of 
the  cases.     According  to  Fedoroff,  the 
best  effects  are  obtained  when  the  mam- 
mary  extract  is   used   hypodermically. 
The  patient  is  thus  placed  in  a  better 
condition  for  any  needed  operation,  and 
often  the  necessity  for  an  operation  is 
postponed.    Where  there  is  evidence  of 
inflammatory  or  degenerative  changes, 
or  when  serious  pressure  symptoms  are 
not  controlled  after  a  reasonable  trial, 
operation  should  not  be  delayed.     The 
mammary  gland  is  also  useful  in  cases 
of     subinvolution     unassociated     with 
malignancy  or  structural  changes. 

Mammary  gland  has  also  given  good 
results,  in  the  hands  of  Pozzi,  in  the 
uterine  hemorrhages  attending  metritis 
of  any  kind.  It  decongests  the  organ 
and  thus  counteracts  inflammation. 

It  has  also  been  recommended  to  as- 
sist uterine  involution  and  to  enhance 
lactation  in  agalactia.  Here,  again,  the 
results  reported  have  been  antagonistic. 
The  dose  is  5  grains  (0.32  Gm.),  re- 
peated several  times  daily,  preferably 
after  meals. 


SPLEEN    ORGANOTHERAPY. 

This  is  based  mainly  on  the  prevail- 
ing opinion  that  the  spleen  destroys  red 
corpuscles  and  creates  new  ones,  and 
that  it  produces  some  sort  of  immuniz- 
ing body,  its  leucocytes,  as  in  lymph- 
glands,  being  phagocytic. 

Extracts  of  spleen  have  been  tried 
in  various  disorders,  including  ex- 
ophthalmic goiter,  the  secondary  ane- 
mias, pernicious  anemia,  chlorosis, 
lymphadenoma,  and  leucocythemia, 
but  the  results  have  not  been  such  as  to 
warrant  further  trial.  Bayle  recom- 
mends it  highly  in  tuberculosis. 

The  writer  considers  spleen  tissue  or 
extract  as  a  specific  for  tuberculosis. 
He  gives  100  Gm.  of  raw  pork  spleen 
tissue  daily  for  three  weeks  and  recom- 
mences again  each  time  after  an  interval 
of  two  weeks.  It  is  readily  taken  in 
soup  or  preserves,  he  says,  or  extracts 
of  the  spleen  may  be  used.  He  com- 
menced this  treatment  about  1903,  and 
now  "has  a  record  of  150  patients  with 
pulmonary  tuberculosis  and  21  with 
bone  or  joint  tuberculosis,  all  given  a 
systematic  course  of  spleen  organo- 
therapy, with  a  complete  cure  in  75  per 
cent,  of  the  patients,  only  4  not  show- 
ing marked  benefit  under  it.  Joly  has 
also  cured  93  per  cent,  of  his  90  pa- 
tients. All  the  local  processes  heal 
under  this  treatment  ten  times  faster, 
the  writer  urges,  than  is  the  case  under 
any  other  methods  of  treatment.  It  is 
readily  applied  and  causes  no  febrile 
reaction  and  no  evil  effects.  Bayle 
(Revue  de  med.,  June,  1911). 

Pancot,  Carpenter,  and  others  claim 
to  have  obtained  good  results  from 
splenic  extract  in  the  treatment  of 
malaria.  Lemansky  found  that  it  en- 
hanced the  action  of  quinine. 

HEPATIC  ORGANOTHERAPY. 

Besides  the  functions  carried  on  by 
the  bile,  which  will  be  referred  to  be- 
low, the  liver  subserves  several  useful 
roles.     It  is  endowed  with  important 


796 


ANIMAL   EXTRACTS    (SAJOUS). 


antitoxic  functions,  all  foodstuffs  ab- 
sorbed through  the  intestinal  mucosa 
entering  the  organ  through  the  portal 
system  for  this  purpose.  It  supplies, 
out  of  the  glycogen  it  forms,  the  blood 
and  tissues  the  sugar  they  contain;  it 
takes  part  in  the  metabolism  of  nitrog- 
enous substances  and  forms  urea.  That 
these  many  phases  of  usefulness  should 
have  suggested  the  use  of  hepatic  sub- 
stance is  not  surprising.  Gilbert  and 
Carnot  found  it  useful  in  various  con- 
ditions. 

In  diabetes  liver  extract  w^as  found 
to  act  with  considerable  energy ;  in  some 
cases,  however,  the  sugar  was  promptly 
diminished,  even  to  nil  occasionally, 
while  in  others  it  increased  it.  I  have 
called  attention  to  the  fact  that  two 
forms  of  diabetes,  the  sthenic  and  as- 
thenic, should  be  clearly  distinguished 
from  each  other,  the  treatment  of  one 
form  being  pernicious  in  the  other.  It 
is  in  the  asthenic  form  that  hepatic  ex- 
tract will  be  found  of  value.  Lere- 
boullet  has  also  observed  beneficial 
effects  in  some  cases. 

Cases  in  which  the  administration  of 
liver  substance  brings  about  improve- 
ment are  those  in  which  the  diabetes 
is  connected  with  a  functional  in- 
adequacy of  the  liver  (characterized  by 
diminution  of  urea,  urobilinuria,  etc.). 
On  the  other  hand,  cases  of  diabetes 
that  are  not  benefited  or  are  even  made 
worse  by  the  treatment  are  those  in 
which  the  glycosuria  appears  to  depend 
on  overactivity  of  the  organ.  Gilbert 
(Inter.  Congress  of  Med.;  Brit.  Med. 
Jour.,  Oct.  13,  1900). 

One  important  feature  of  liver  ther- 
apy is  that,  as  emphasized  by  practical 
experience,  the  remedy  causes  diuresis 
in  subjects  who  suffer  from  hepatic  in- 
sufficiency in  some  form  and  par- 
ticularly when  it  occurs  in  the  course 
of  cirrhosis.     The  diuresis  is  also  ac- 


companied by  increased  urea   elimina- 
tion. 

Case  of  cirrhosis  of  the  liver  with 
abundant  edema  and  ascites;  the  liver 
was  small,  the  spleen  much  enlarged, 
and  the  collateral  circulation  very 
marked.  The  patient  was  put  upon  a 
milk  diet  and  given  about  4  ounces  of 
fresh  pork  liver  mixed  with  bouillon. 
Abdominal  puncture  resulted  in  the 
withdrawal  of  4  quarts  of  fluid  besides 
what  oozed  from  the  wound  during 
several  days  following.  The  urine  was 
rapidly  increased  to  over  90  ounces  a 
day;  this  is  considered  a  valuable  prog- 
nostic sign.  Gradually  the  edema  and 
the  collateral  circulation  disappeared 
and  there  was  no  return  of  the  ascites. 
Unfortunately,  the  results  in  all  cases 
are  not  so  favorable  as  in  this.  M. 
Hirtz  (La  presse  medicale.  No.  52,  p. 
413,  1904). 

Case  of  tuberculous  peritonitis  and 
cirrhosis  of  the  liver  which  when  first 
seen  presented  general  anasarca,  dysp- 
nea, albuminuria,  and  hematuria.  After 
being  treated  four  months,  during 
which  time  tapping  was  often  necessary, 
irrigations  of  10  ounces  of  a  pulp  made 
from  pigs'  liver  were  prescribed.  In 
less  than  two  months  there  was  marked 
improvement :  the  hematuria  was  less, 
tapping  was  no  longer  necessary,  and 
the  masses  in  the  peritoneum  had  de- 
creased in  size.  The  patient  continued 
to  improve  rapidly  and  returned  to 
work.  The  writer  reports  a  second 
similar  instance  in  which  just  as  re- 
markable a  cure  was  attained.  Desplats 
(Jour,  de  sci.  med.  de  Lille,  No.  30,  p. 
73,  1905). 

Case  of  atrophic  cirrhosis  with 
ascites.  On  admission  paracentesis  was 
performed  and  about  7  quarts  of  fluid 
withdrawn.  Seven  hours  later  a  second 
tapping  seemed  necessary,  but  hepatic 
extract  was  prescribed  instead.  Marked 
and  rapid  diuresis  resulted,  and  the 
general  state  of  the  patient  became 
much  improved.  This  form  of  treat- 
ment, according  to  the  observer,  should 
give  excellent  results  in  the  precirrhotic 
stage  of  this  disease.  J.  Carles  (Revue 
de  therapeutique,  No.  11,  p.  387,  1906). 


ANIMAL    EXTRACTS    (SAJOUS). 


797. 


In  a  case  of  cirrhosis  of  long  dura- 
tion   in    which    the    daily    excretion    of 
urine  did  not  exceed  450  Gm.,  ten  days' 
treatment    with    hepatic    extract    raised 
the    flow    to    a    quart    (1000    Gm.)    and 
more.      Interruption    of    the    treatment 
caused  resumption  of  oliguria,  soon  fol- 
lowed    by     death.       Cases     of     marked 
diuresis  after  the  use  of  hepatic  extract 
have    been    reported   by   many    authors, 
Gilbert  and   Carnot,  Widal,   Hirtz,  and 
others.     M.  Perrin  (Paris  medical,  Dec. 
16,  1911). 
In    alcoholic    cirrhosis    it    was    also 
found  of  value  by  Gilbert  and  Carnot. 
The  edema,  jaundice,  and  hemorrhages 
were   kept   in   abeyance    in   a   case   re- 
ported, returning  whenever  the  use  of 
liver  extract  was  interrupted. 

The  coagulating  action  of  liver  on 
the  blood,  shown  by  Gilbert  and  Car- 
not, was  carefully  .studied  by  Berthe. 
The  patients  on  whom  the  observations 
were  made  were  tuberculous,  and  had 
suffered  repeatedly  from  hemoptysis, 
which  had  not  responded  to  any  ordi- 
nary treatment.  In  all  cases  the  results 
were  rapid.  The  method  was  also  tried 
in  cases  of  epistaxis  and  metrorrhagia. 
The  method  consisted  in  giving  an  ex- 
tract of  liver,  about  3  drams  (12  Gm.) 
for  a  dose,  in  tepid  soup.  This 
amount  will  in  many  cases  suffice,  but 
can  be  repeated  when  necessary.  It 
can  also  be  administered  per  rectum  in 
the  same  dose.  One  of  the  best  and 
most  suitable  preparations  is  the  desic- 
cated liver.  The  glycerin  extract  is 
also  efficacious.  Should  it  not  be  pos- 
sible to  procure  a  ready-made  extract, 
an  emulsion  of  liver  freshly  prepared, 
and  given  in  the  form  of  an  enema, 
seems  to  act  perfectly  well,  3  to  6 
ounces  (94  to  186  Gm.)  being  finely 
chopped  up  and  then  rubbed  up  with 
water,  about  4%  ounces  (140  Gm.)  of 
liver  being  used.  Fresh  pigs'  liver  is 
one  of  the  best  sources  of  preparation. 


Liver  extract,  now  available  on  the 
market,  has  also  been  used  with  advan- 
tage in  chronic  gastrointestinal  intox- 
ication, the  object  being  to  check  the 
growth  of  bacterial  flora.  Biliary  acids, 
referred  to  below,  are,  however,  prefer- 
able. A  convenient  way  is  to  use  the 
biliary  extract  in  suppositories. 

AVhile  liver  extract  gives  uncertain 
results  in  diabetes,  its  use  in  the  form 
of  suppositories  night  and  morning  is 
of  positive  value  in  chronic  gastroin- 
testinal autointoxication,  a  relatively 
common  disorder.  O.  L.  Mulot  (Long 
Island  Med.  Jour.,  Dec,  1910). 

BILE,  BILE-SALTS,  AND  BIL- 
IARY EXTRACTS. 

The  use  of  hile  in  therapeutics  is 
based  on  a  sounder  basis  than  that  of 
several  of  the  foregoing  agents,  its  ex- 
citomotor  action  on  the  intestine,  now 
fully  demonstrated,  serving  various  use- 
ful purposes.  It  counteracts  constipa- 
tion due'  to  intestinal  atony,  and  thus 
prevents  autointoxication  of  intestinal 
origin,  which,  in  turn,  produces  cholan- 
gitis by  allowing  the  return  into  the 
portal  system  of  excretory  products 
which  should  have  escaped  normally 
with  the  intestinal  discharges.  Again, 
bile,  as  shown  by  Pawlow,  is  a  physio- 
logical auxiliary  to  the  pancreatic  juice, 
augmenting  its  activity  threefold.  As 
is  well  known  also,  bile,  or  gall,  in- 
creases the  solubility  of  cholesterin, 
thus  preventing  the  formation  of  gall- 
stones. Bile  is  also  endowed  with  anti- 
toxic properties. 

Series  of  experiments  upon  rabbits 
consisting  of  direct  injection  into  the 
exposed  gall-bladder  of  bacteria  of 
various  species  and  virulence.  The  bile 
was  found  to  contain  some  substance 
which  interfered  with  the  development 
of  most  varieties  of  colon,  typhoid,  and 
diphtheria  bacilli,  the  different  bacteria 
varying  greatly  in  their  susceptibility 
to  the  unfavorable  influence  of  the  bile. 


798 


ANIMAL   EXTRACTS    (SAJOUS). 


The  bactericidal  action  of  the  bile 
varied  at  different  times  and  with  dif- 
ferent animals.  One  of  the  most  im- 
portant factors  influencing  the  result  of 
the  injections  was  the  number  of  bac- 
teria that  reached  the  bile  passages. 
The  liver-cells  and  the  epithelial  cells 
of  the  bile  passages  strongly  resisted 
any  attempt  at  entrance  on  the  part 
of  bacteria;  this  was  particularly  strik- 
ing with  diphtheria  bacilli.  S.  Talma 
(Zeit.  f.  klin.  Med.,  Bd.  xlii,  Heft  5  u. 
6,  1901). 

In  101  specimens  of  bile,  organisms 
were  recovered  in  8  cases,  and,  from  12 
calculi,  organisms  were  recovered  in 
six  instances.  The  organisms  observed 
most  frequently  were  of  the  colon  type. 
In  Zl,  pure  cultures  of  the  colon  bacillus 
were  obtained,  and,  in  association  with 
other  organisms.  Bacillus  coll  was  ob- 
served 35  times.  The  typhoid  bacillus 
was  recovered  in  two  instances :  one 
in  which  typhoid  fever  had  existed 
thirteen  years  previously,  and  in  the 
second  instance  from  a  person  dying 
as  a  result  of  typhoid  perforation.  A 
large  Gram-positive  bacillus  was  also 
found  in  26  cases.  This  organism  was 
morphologically  and  tinctorially  iden- 
tical with  the  Bacillus  aerogenes  cap- 
sulatus.  This  organism  developed  abun- 
dantly in  the  bouillon  cultures  where 
colon  and  other  organisms  developed. 
Williams  (N.  Y.  Med.  Jour.,  May  13, 
1911). 

The  therapeutic  use  of  bile  or  bile 
constituents  is  thus  based  on  a  solid 
foundation.  They  may  be  used  as 
stated  above,  in  constipation  and  putre- 
faction due  to  hepatic  and  intestinal 
atony,  autointoxication  of  intestinal 
origin,  in  cholangitis  and  the  resulting 
jaundice,  and  also  to  prevent  the  for- 
mation of  gall-stones.  They  have  also 
been  used  advantageously  in  enteroco- 
litis in  its  membranous  form. 

Study  of  IS  cases  from  a  metabolic 
standpoint  which  seem  to  indicate  that 
the  administration  of  bile  in  certain 
conditions  is  based  upon  rational  thera- 
peutics.    Consequently,  the  writers  ad- 


vocate the  administration  of  bile  in 
jaundice  due  to  various  causes.  Ab- 
sorption of  fat  is  increased;  it  also  has 
a  laxative  effect.  The  writers  give  in- 
spissated oxbile  in  sweetened  aromatic 
water  in  doses  of  from  0.5  to  1  Gm. 
one  hour  before  meals.  Given  with 
considerable  water  it  will  not  disturb 
gastric  digestion.  Inouye  and  Sato 
(Arch.  f.  Verdauung-Krank.,  Bd.  xvii, 
185,  1911). 

Mucomembranous  enterocolitis  and 
constipation  being  the  result  of  insuffi- 
ciency of  the  biliary  secretion,  their 
treatment  becomes  simple.  The  general 
indications  are:  (1)  reduction  to  a 
minimum  of  the  quantity  of  toxic  and 
putrefactive  products  in  the  intestine  by 
an  appropriate  diet;  (2)  shortening  of 
the  period  of  transit  of  food  through 
the  alimentary  canal  and  prevention  of 
the  coagulation  of  mucus  by  the  use  of 
a  cholagogue,  the  best  of  which  is  bile 
itself.  The  writer  uses  an  extract  de- 
void of  putrescible  nucleoalbumins, 
which  he  has  termed  antimucose,  avail- 
able in  0.20-Gm.  (3.1  grains)  dragees; 
suppositories,  and  ampules  of  50  c.c. 
(1.7  fluidounces)  in  which  the  biliary 
substances,  dissolved  in  water,  occur  in 
the  concentration  of  normal  bile.  H. 
Nepper  (Monthly  Cyclopedia  and  Med. 
Bull,  Jan.,  1912). 

Although  cholic  acid  is  the  most 
active  of  the  bile-salts,  salts  of  glyco- 
cholic  or  taurocholic  acid  are  preferred. 
They  possess  all  the  therapeutic  prop- 
erties of  oxgall.  The  sodium  glyco- 
cholate  or  taurocholate  can  be  conveni- 
ently used  in  ^-  to  3-  grain  (0.032  to 
0.19  Gm.)  doses  three  times  a  day.  Or, 
the  extract  of  bile  may  be  given  in  5- 
to  15-  grain  (0.32  to  1.0  Gm.)  doses 
after  meals,  with  a  draught  of  water. 
Bile  may  also  be  injected  into  the  rec- 
tum to  cause  its  evacuation.  This  is 
especially  valuable  in  paralytic  ileus, 
postoperative  and  peritonitic  atony, 
or  paresis  of  the  intestine  from  any 
cause. 


ANIMAL    EXTRACTS    (SAJOUS). 


799 


Bilo  acids  may  bo  (.'nipl(\vc(l  with 
])nipricty  chiclly  in  three  rdiuHtinns: 
intestinal  putrefaction,  hepatic  insuffi- 
ciency, gall-stone  disease,  and  the 
various  syiulrDiiies  known  to  be  con- 
secutive to  these  states.  The  writer 
employs  glycocholic  acid,  in  the  form 
of  the  sodium  salt,  because  it  is  more 
readily  procurable  and  cheaper  than 
taurocholic  acid.  The  dose  varies  ac- 
cording to  the  exigencies  of  the  case. 
The  writer  has  been  in  the  habit  of 
giving  J^-grain  doses  at  frequent  inter- 
vals until  the  desired  effect  is  produced. 
There  is  never  any  danger  of  giving  too 
much  because  the  sodium  glycocholate 
in  no  way  deranges  the  stomach,  and,  if 
given  in  very  large  doses,  merely  occa- 
sionally produces  a  little  diarrhea, 
which  promptly  carries  off  the  surplus. 
Croftan  (N.  Y.  Med.  Jour.,  April  2, 
1906). 

The  preferred  preparation  is  the  ex- 
tract of  oxgall,  the  minimum  dose  of 
which  is  from  7^  to  15  grains  admin- 
istered in  pill  form  after  meals.  In  ex- 
treme instances  it  may  be  necessary  to 
give  as  large  a  quantity  as  75  grains, 
but  such  doses  should  not  be  continued. 
The  pills  should  be  coated  with  keratin 
or  similar  substances,  so  that  their  con- 
tents may  not  be  set  free  until  they 
reach  the  intestine.  The  patient  should 
be  advised  to  drink  more  than  the  usual 
amount  of  water  in  order  that  the  in- 
creased quantity  of  bile  which  is  ex- 
creted as  a  result  of  the  medication  may 
not  become  inspissated.  M.  Nigay 
(Revue  de  therap.,  387,  1906). 

Bile  administered  per  rectum  leads 
to  prompt  evacuation  of  the  bowels, 
peristalsis,  as  shown  by  studies  in  dogs, 
being  set  up  chiefly  in  the  large  intes- 
tine. Bile  acids  are  the  active  con- 
stituents of  the  bile.  Cholic  acid  acts 
most  powerfully,  though  taurocholic 
and  glycocholic  acids  also  cause  active 
peristaltic  movements.  Because  of  the 
expense,  the  extensive  use  of  cholic 
acid  is  precluded.  "Platner's"  bile  has 
been  found  to  be  a  suitable  substitute, 
given  in  doses  of  0.2  to  0.5  Gm.  As 
a  rule,  the  patient  has  a  stool  in  five  to 
fifteen  minutes  after  administration  per 


rectum.  The  stool  is  formed  with  no 
excess  of  lluid.  Glaessner  and  Singer 
(Wien.  klin.  VVoch.,  Bd.  xxiii,  S.  5, 
1910). 

HORMONES. 

Baylis.s  and  Starling  termed  "secre- 
tin" a  hormone  formed  in  the  duodenal 
mucous  luembrane  under  the  inlluence 
of  hydrochloric  acid  from  the  stomach. 
Carried  by  the  circulation  to  the  intes- 
tinal mucosa,  the  pancreas,  and  the 
liver,  it  activates  the  production  of  the 
secretions  produced  by  these  organs. 
From  my  viewpoijit, .  as  I  suggested  in 
1907  ("Internal  Secretions  and  the 
Principles  of  Medicine,"  vol.  ii,  p.  861), 
this  hormone  presents  several  proper- 
ties of  adrenal  extractives.  Be  this  as 
it  may,  the  question  has  not  been  suffi- 
ciently developed  as  yet  to  warrant  any 
conclusion  as  to  the  exact  mode  of  ac- 
tion of  these  substances. 

Another  hormone,  however,  has  been 
obtained  from  the  gastric  mucosa  by 
Zuelzer,  Dohrn,  and  Marxer  (Berl. 
klin.  Woch.,  Nu.  46,  1908)  which  has 
been  found  to  enhance  peristalsis.  It 
being  impossible  to  obtain  it  in  sufficient 
quantities  from  the  stomach,  it  was 
sought  after  elsewhere,  and  was  found 
in  ample  quantities  in  the  spleen — that 
junkshop  in  which  red  corpuscles 
(which,  as  I  suggested  in  1903,  are  the 
common  carriers  of  the  adrenal  prin- 
ciple) are,  broken  up  along  with  other 
cells.  This  splenic  hormone  specifically 
stimulates  intestinal  peristalsis  to  a  de- 
gree so  remarkable  rtiat  the  intestinal 
movements  in  the  experimental  animal 
may  readily  be  shown  cinematograph- 
ically  ten  to  fifteen  minutes  after  an 
intravenous  injection. 

This  hormone  (available  as  hormonal 
in  the  trade)  has  been  found  of  con- 
siderable value  in  chronic  ronstipa- 
tion,  intravenous  injections  (20  c.c. — 5 


800 


ANIMAL   EXTRACTS    (Sx\JOUS). 


drams)  giving  71  per  cent,  of  recov- 
eries, beginning  from  the  second  to 
the  seventh  day  and  lasting  from  six 
months  to  two  years  (Zuelzer).  The 
injection  gives  but  Httle  local  pain  thus 
used,  and  causes  a  sHght  rise  of  tem- 
perature (hormone  fever).  In  intestinal 
paralyses  following  abdominal  opera- 
tions or  volvulus  it  has  also  given  sat- 
isfactory results  in  some  cases. 

Series  of  6  cases  of  grave  intestinal 
paralysis  which  had  resisted  all  other 
means.  Hormone  injections  caused  gen- 
eral improvement  .and  the  emission  of 
gas  in  from  one  to  five  hours  after  the 
injection.  But  the  effect  did  not  seem 
to  be  lasting.  It  is  advisable  to  enhance 
the   action  by   means   of   enemata   and 


purgatives  to  insure  the  elimination  of 
the  intestinal  contents.  Henle  (50th 
German  Congress  of  Surgery,  April, 
1911).     - 

In   intestinal   occlusion   the  use   of 

hormones  has  been  recommended,  but 
care  is  necessary  lest  the  violent  peri- 
stalsis provoked  aggravate  any  intes- 
tinal lesion  that  may  be  present. 

The  writers  recall  that  four  years  be- 
fore Zuelzer  did  so  they  isolated  the 
substance  which  in  the  intestinal  mucosa 
promotes  peristalsis,  and  to  which  the 
term  "peristaltic  hormone"  was  subse- 
quently applied.  Enriquez  and  Hallion 
(C.-r.  de  la  Soc.  de  Therapeutique,  Oct 
25,  1911). 

C.  E.  DE  M.  Sajous, 

Philadelphia. 


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DATE  BORROWED 

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RC41 


SaZ 
1918 


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